- ' ** 



■ I 



■ 



A M A JST U A L 



AUSCULTATION AND PERCUSSION. 



A MANUAL 



AUSCULTATION AND PERCUSSION. 



M. BAETH, 

AND 

M. HENRI EOGEE. 



TRANSLATED FROM 



THE SIXTH FRENCH EDITION. 



PHILADELPHIA: 

LINDSAY AND BLAKISTON. 

1866. 



<^2 






Entered, according to Act of Congress, in the year 1866, 

By LINDSAY & BLAKISTON, 

In the Clerk's Office of the District Court of the United States for the 
Eastern District of Pennsylvania. 



SHERMAN & CO., PRINTERS. 



PREFACE. 



Hardly had auscultation been created by the 
genius of Laennec, than it was welcomed as one 
of the most precious discoveries by all those 
who are interested in the progress of medicine. 
The signal services that it renders to the science 
of diagnosis, cannot be called in doubt by whom- 
soever will take the pains to make himself ac- 
quainted with the working of the new method. 
The invention was too great not to strike im- 
partial minds at once. The emulation to which 
it gave birth, the efforts that were afterwards 
made, either to give greater precision to its re- 
sults, or to enlarge its domain, are a proof of its 
importance; and the extension which observers 
have given to it, the happy applications which 
have been made of it to the more exact and 
complete study of the diseases of the circulatory 
apparatus, to obstetrics and to surgery, testify 
1* 



VI PREFACE. 

to the impulse which it has given to the whole 
science of medicine. 

Nurtured by the study of the magnificent 
work of Laennec, we have for a number of 
years abandoned ourselves with ardor to the 
practice of auscultation; and after having dis- 
played in oral lessons the principles of stethos- 
copy; after having taught its application at the 
bedside of the sick; we thought that a book would 
facilitate its study, and spread the knowledge of 
it. It has appeared to us useful to collect into 
a treatise the precepts of Laennec, the facts 
that he proved, and the new discoveries which 
have resulted from the labor of observers in all 
countries. 

Besides, we have not limited ourselves to gath- 
ering up these scattered elements of science : 
being both of us hospital physicians, and de- 
voted to clinic observation, we have added our 
own knowledge to the treatise, both by criti- 
cizing the facts of which auscultation is com- 
posed, and by some new discoveries. 

In the study of the symptoms which come to 
the knowledge of the physician by the medium 
of hearing, we have taken care to establish the 
rules whose practice is of consequence to the 
exact perception of sensations; then we have 



PREFACE. Vll 

described the sonorous phenomena perceptible 
in the physiological and pathological conditions. 
Then having pointed out a single morbid sound, 
we have examined its characteristics, its differ- 
ential diagnosis, its signification, and its semei- 
ological value. 

We desire those who are entirely novices in 
auscultation, to hold fast to this treatise at first, 
but afterwards, when their senses are more ex- 
ercised, and their medical knowledge more ex- 
tensive, to recur to its data, either to enlighten 
doubtful points, or to complete their first opin- 
ions. 

In adding to the Compendium of Auscultation 
an appendix, in which we succinctly expose the 
principal ideas relative to percussion, we have 
not pretended, in so small a number of pages, to 
compose a treatise on pleximetry. But, as in 
practice the two methods are constantly assist- 
ing each other, we thought that to bring to- 
gether their data, and to display their results, 
as it were, simultaneously, would facilitate the 
study of the physical diagnosis of diseases. 

In closing, let us repeat what we have said 
before. 

We have studied facts without preconceived 
opinions, without preoccupation of theories, and 



Vlll PREFACE. 

without respect to persons; we have spoken 
them with sincerity; and when we have com- 
bated opinions which were in opposition to our 
own, we hope that we have done it with that 
decorum of language which belongs to scientific 
discussions. In everything w T e have had but one 
aim, utility; but one motive, the love of truth. 
We wish also to preserve our liberty of thought, 
convinced of the correctness of our opinions, and 
in the mean time ready to modify them if our 
own researches, or those of others, should prove 
to us that truth is to be found elsewhere. To 
change thus is to follow progress, and it is to- 
wards progress that all our efforts shall tend.* 

* Extracted from the larger work of Messrs. Barth 
and Koger, " Traite Pratique d' Auscultation, &c. Paris. 
1865.' 7 — Trans. 



TABLE OF CONTENTS. 



CHAPTEK I. 

Auscultation of the Respiratory Apparatus. 



Art. I. — The Eespiratory Murmur, 
& 1. Normal Kespiration, 
§ 2. Changes in the Eespiratory Murmur, 
1st. Changes in Intensity, . 

A. Strong or Puerile Kespiration, 

B. Feeble Kespiration, 

C. Kespiration that is Null, 
2d. Changes in Khythm, . 

3d. Changes in Character, . 

A. Harsh Kespiration, 

B. Bronchial or Tubal Kespiration, 

C. Cavernous Kespiration, . 

D. Amphoric Kespiration, . 
| 3. Changes by Anomalous Sounds, 

First Kind — Kattling (Kales), 
1st. Vibrating Battles, 
2d. Blebby Kattling, .... 

A. Crepitating Kattle, 

B. Subcrepitating Kattle, . 

C. Cavernous Kattle, . 



PAGE 
13 

13 
14 
14 
15 
15 
16 
17 
18 
18 
19 
20 
21 
21 
23 
23 
24 
24 
25 
27 



Appendix, ....... 28 



X TABLE OF CONTENTS. 

PAGE 

Art. II. — Auscultation of the Voice, . . 28 

A. The Exaggerated Kesounding of the 

Voice, or Slight Bronchophony, . 29 

B. The Bronchial Voice, ... 29 

C. The Tremulous Voice, ... 30 

D. The Cavernous Voice, ... 31 

E. Amphoric Voice, .... 32 



Art. III. — Auscultation of the Cough, . 
Metallic Tinkling, . 
Sound of Thoracic Fluctuations, 



32 
34 
35 



\ 
Art. IV. — Auscultation of the Larynx, . 35 



CHAPTER II. 

Auscultation of the Circulatory Apparatus. 



Art. I. — Auscultation of the Heart, . 

$ 1. Physiological Phenomena, 
\ 2. Pathological Phenomena, . 

1st. Changes of Seat, .... 
2d. Changes in Intensity and Extent, 
3d. Changes in Rhythm, . 
4th. Changes in Character, 
5th. Anomalous Sounds of the Heart, 
First Kind — Sounds of Souffle, 

A. Soft Sound of Souffle, . 

B. Sounds of Rasp, File, and Saw, 

C. Musical Sounds, "Whistling, Whin 

ing (piaidement), 
Second Kind — Sounds of Friction, 



38 
39 
41 
41 
42 
43 
45 
46 
47 
47 
55 

56 

57 



TABLE OF CONTENTS. 


xi 




PAGE 


Art. II. — Auscultation of the Great Vessels, 


58 


1. Aortic Sounds, ..... 


59 


2. Vascular Sounds, ..... 


62 


A. Arterial Sounds, . . . 


63 


B. Vascular Sounds, Venous and 




Mixed, 


64 


CHAPTEK III. 




Auscultation or the Abdoi\ien, 


65 



CHAPTEK IV. 

Auscultation of the Head, .... 67 

CHAPTEK V. 

Auscultation oe the Members, ... 69 



CHAPTEK VI. 

Obstetrical Auscultation, .... 70 

A. The Uterine Souffle, ... 70 

B. Sounds of Displacement of the 

Foetus, ...... 71 

C. Sounds of the Foetal Heart, . . 71 



CHAPTEK VII. 
Dynamism, . . 73 



Xll TABLE OF CONTENTS. 



PERCUSSION, 

General Eules, 
Division, 



Sec. I. Percussion of the Chest, 

Chapter I. — Pulmonary Apparatus, 
§ 1. Especial Eules, . . . . • . 
$ 2. Physiological Phenomena, 
§ 3. Pathological Phenomena, . 

Chapter II. — Circulatory Apparatus, 

Percussion of the Heart and the Great Vessels 

§ 1. Especial Rules, 

g 2. Physiological Phenomena, 
§ 3. Pathological Phenomena, . 

Sec. II. Percussion of the Abdomen, 

§ 1. Especial Rules, 

\ 2. Physiological Phenomena, 
\ 3. Pathological Phenomena, 



PAGE 

76 
79 
89 

89 

89 
89 
91 
95 

111 
111 
111 
112 
114 

117 
117 
119 
122 



Sec. III. Percussion of the Head, the Neck, 

the Spine, and the Members, . 150 

Percussion and Auscultation Combined, . 152 



MANUAL OF 

AUSCULTATION AND PERCUSSION, 



Chapter L 

The auscultation of the respiratory appara- 
tus is exercised upon the thorax, and upon 
the laryngotracheal tube; it has for its object, 
the study of three orders of phenomena, fur- 
nished by the respiratory murmur, the voice, 
and the cough. 

.a_:r,T- I. 

THE RESPIRATORY MURMUR. 
I 1. Normal Respiration. 

If, in the physiological state, the ear is ap- ' 
plied to the breast of a person breathing, there 
is heard a light murmur, analogous to that 
which is produced by a person sleeping peace- 
fully, or heaving a deep sigh; this is the 

2 



14 AUSCULTATION. 

natural respiratory sound, or the vesicular 
murmur. Soft and mellow to the ear, it is 
composed of two distinct sounds, that of in- 
spiration, which is more intense and more 
prolonged, and that of expiration. 

The vesicular murmur is strongest in those 
points which correspond to a greater thick- 
ness of the lungs; it is a little more harsh 
towards the roots of the bronchi (normal 
bronchial respiration). Equal on both sides, 
in those points which correspond to each 
other, it is in some persons a little more in- 
tense at the top of the right lung. More 
loud when the respiration is full and rapid ; 
its force is also increased in children (puerile 
respiration); on the contrary it is weaker in 
the old. Generally its intensity increases in 
proportion as the chest is large, and its walls 
are thin. 

§ 2. Changes in the Kespiratory Murmur. 

These may be divided into four classes, — 
1st. Changes in intensity ; 2d, in rhythm ; 3d. 
in character; 4th, alteration by anomalous 
sounds. 

1st. Changes in Intensity. 

Considered under this point of view, respi- 
ration may be either strong, feeble, or null* 



CHANGES IN INTENSITY. 15 

A. Strong or Puerile Respiration. — This con- 
sists of a vesicular murmur, whose intensity 
is greater than in the normal state, preserv- 
ing however the soft and mellow character of 
the respiration. It announces not so much a 
lesion in the pulmonary organs, in that point 
at which it is heard, as disease in a portion 
more or less distant, the healthy parts in this 
case supplying the inaction of the affected 
parts. 

B. Feeble Respiration. — This is character- 
ized by a diminution in the normal force of 
the vesicular murmur, the latter preserving 
at times its natural softness, at times becom- 
ing a little more harsh. This proceeds either 
from the sound being transmitted less com- 
pletely to the ear, or being produced with 
less intensity. 

In the first case, this feeble expiration may 
be caused by pleuritic effusions, by thick 
pseudo-membranes deposited upon the pleu- 
r?e, or by tumors, which remove the lung 
from the walls of the thorax. 

In the second case, its causes will be recog- 
nized as pleurodynia, contractions of the lar- 
ynx, partial obstruction of one or more of the 
bronchial branches by a mass of mucus, or 
by a foreign body; the narrowing of their 



16 AUSCULTATION. 

cavity or the compression of their walls by 
tumors. It is also met with in pulmonary 
emphysema, and in the first degree of phthisis. 

Of all the diseases that we have just enu- 
merated, and which are often made known 
by a feeble respiration, tubercles, pulmonary 
emphysema, and liquid effusions within the 
pleura being much the most frequent (bron- 
chitis, which is also common, has its own 
especial rattling), the physician ought to de- 
vote his attention almost exclusively to these. 
If the feebleness of the vesicular murmur co- 
incides with an exaggerated sonorousness of 
the thorax, there is emphysema; with dul- 
ness, there are tubercles or there is pleural 
effusion. If feeble respiration, accompanied 
by dulness, is limited to the top of the lung, 
there are probably tubercles ; if it is circum- 
scribed below, there is probably pleuritic effu- 
sion ; if it exists at the two apexes, there are 
almost certainly tubercles of the two sides; if 
it exists at the base of the two lungs, there is 
double pleurisy, or rather double dropsy of 
the chest. 

C. Respiration that is Null — We say that 
the respiration is null when the ear, applied 
to the chest, hears absolutely nothing; the 
vesicular murmur is also wanting, and no 



CHANGES IN RHYTHM. 17 

sound takes its place; the silence is com- 
plete. 

Respiration that is null is governed by the 
same physical conditions as feeble respiration, 
consequently it announces the same diseases, 
with this difference, that it indicates more 
decided anatomic lesions. But the complete 
silence of the respiratory murmur being near- 
ly exceptional in emphysema and in tuber- 
cles ; the diseases of the larynx revealing 
themselves by especial phenomena; the ob- 
literation of the bronchi, their obstruction 
by foreign bodies, as well as pneumothorax 
without perforation, etc., being rare affec- 
tions in comparison with liquid effusions 
within the pleura, it results from these facts, 
that respiration which is null is a symptom 
of very great value, a frequent indication of 
these effusions, and, as most frequently, pleu- 
risy is single, and dropsy of the chest is double, 
it follows that the silence of the respiratory 
murmur, declared by a single side of the chest, 
almost certainly announces pleurisy with effu- 
sion. 

2d. Changes in Rhythm, 

Respiration which is changed in rhythm, 
may be slow (from twelve to seven inspira- 

2* 



18 AUSCULTATION. 

tions in a minute) as in many diseases of the 
cerebro-spinal apparatus, or frequent (from 
30 to 80) as in a great number of thoracic or 
abdominal affections. Sometimes it is jerky, 
in asthma, in pleurodynia, at the commence- 
ment of phthisis, in chronic pleurisy with ad- 
hesions, etc. 

Sometimes it is long, sometimes short; 
finally at times there is prolonged expiration, 
and then almost always the respiratory sound 
is at the same time more harsh. 

Of these different changes, the last alone is 
of importance in diagnosis. We may say 
that prolonged expiration is the indication of 
two diseases alone : pulmonary emphysema, 
or tubercles at the stage of formation. In 
some cases, it is the first or only stethoscopic 
symptom of phthisis. 

3d. Changes in Character. 

A. Harsh Respiration. — This displays vari- 
ous degrees of force, of harshness, of dryness, 
and these changes affect both expiration and 
inspiration, or either alone. 

It is met with in emphysema of the lung, 
at the commencement of phthisis, finally in 
all cases where there is pulmonary induration 
(melanosis, chronic pneumonia, etc.) Of all 



CHANGES IN CHARACTER. 19 

these diseases emphysema and phthisis most 
frequently produce harshness in the respira- 
tory sound. If this harshness is joined to 
dryness, coincident with hollowness and ex- 
aggerated sonorousness of the thorax, it indi- 
cates pulmonary emphysema; if harsh respi- 
ration is accompanied by a sound of prolonged 
expiration, if it is limited to the top of the 
chest, with resonance of the voice, and dul- 
ness on percussion, we must diagnosticate 
newly formed tubercles. 

B. Bronchial or Tubal Respiration. — Re- 
markable at once for an augmentation of 
intensity, and a more elevated tone, bronchial 
respiration is well imitated by inhaling and 
exhaling through the hand, when rounded to 
a tube, or through the stethoscope ; the more 
swiftly and forcibly we breathe, the more 
nearly we approach the tubal breathing. 

When it is slightly marked, bronchial res- 
piration differs but little from harsh respira- 
tion, of which it is but an exaggeration. 
When w r ell defined, it has a peculiar tone 
— tubal — which serves to distinguish it from 
cavernous respiration, which generally has a 
hollow character peculiar to itself. 

Bronchial respiration may be heard in a 
great number of affections of the pleurae, of 



20 AUSCULTATION. 

the bronchi, and especially of the lungs, 
such as inflammatory hepatization, consider- 
able agglomeration of tuberculous matter, 
extended pulmonary apoplexies, etc.; liquid 
effusions of the pleurae, various tumors com- 
pressing the lung; finally, uniform dilatation 
of the bronchi, with hardening of the sur- 
rounding tissue. 

Of all these diseases, the most frequent are 
pulmonary phthisis, pleurisy, and pneumonia. 

If this bronchial respiration is but little 
marked, circumscribed at the top of the tho- 
rax, and supervening on a chronic disease, it 
should be attributed to the presence of newly 
formed tubercles in the parenchyma of the 
lung. If the bronchial murmur is more in- 
tense, if it shows itself in an acute affection 
of the chest, we can only think of pleurisy or 
pneumonia; if it is proportioned neither to 
the intensity nor to the extent of the dulness 
of the thorax, it is rather the indication of 
pleuritic effusion ; if, on the contrary, it is in- 
tense, truly tubal, and if it is perceived in the 
whole extent of the dulness, there is reason 
to believe in the existence of pulmonary he- 
patization. 

C. Cavernous Respiration. — This resembles 
the sound which is made by breathing into 



CHANGES BY ANOMALOUS SOUNDS. 21 

a hollow space. It is imitated by inspiring 
and expiring with force into the two hands, 
placed in the form of a cavity. Its habitual 
seat is in the top of the chest. 

It announces the dilatation of a bronchus 
into a somewhat voluminous cavity, or the 
existence of a cavern, properly speaking. 
But on account of the rareness of bronchial 
dilatations and of pulmonary excavations fol- 
lowing abscess, gangrene, etc., compared to 
the frequency of phthisis, we may conclude 
that, nine times in ten, cavernous respiration 
will indicate a cavern resulting from the soft- 
ening of tubercles. 

D. Amphoric Respiration. — This is a resound- 
ing noise, a metallic tone, which is well imi- 
tated by blowing into a hollow pitcher, or 
into a decanter with resounding sides. It co- 
incides almost always with the metallic tink- 
ling. Well-marked amphoric respiration in- 
dicates almost infallibly pneumothorax with 
pulmonary fistula. Ill-defined, it may an- 
nounce the same disease, but be the symptom 
also of a vast cavern, almost always tubercu- 
lous. 

\ 3. Changes by Anomalous Sounds. 

Anomalous sounds are of two kinds, — 
rattling and the sound of friction. 



22 AUSCULTATION. 



First Kind. — Sound of Friction. 

Pleuritic Friction. — The two leaves of the 
pleura, in their normal condition, glide upon 
each other in silence during the motion of the 
lungs; but when certain pathological condi- 
tions are met with, there is a friction accom- 
panied by noise. Pleuritic friction, somewhat 
analogous to the rubbing of parchment more 
or less dry, is generally jerky, and as if com- 
posed of several successive crackings. It 
presents varieties of harshness and of inten- 
sity, w r hich has been the cause of admitting 
two varieties — a gentle friction, or grazing, 
and a harsh friction or scraping. When it is 
veiw strong, it may be felt by the hand ap- 
plied to the thorax; at times the patient 
himself can feel it. In order to produce the 
sound of friction, the leaves of the pleura, or 
at least one of them, must present asperities, 
and they must glide upon each other in the 
motion of raising and depressing the ribs. 
These asperities depend almost always on the 
presence of false membranes, deposited on 
the surface of the pleurae. 

We meet with pleuritic friction in pleurisy, 
in certain cases of tubercles of the pleura, 
without adhesions, in some other organic 



RATTLING. 23 

changes of this membrane, and very rarely 
in some varieties of pulmonary emphysema; 
but most frequently this phenomenon indi- 
cates pleurisy in process of cure. If it were 
heard exclusively at the top of the chest, we 
might suspect tuberculous pleurisy. 

Second Kind. — Rattling. {Rales.) 

Rattlings are anomalous noises formed 
during the act of breathing by the air, as it 
traverses the air-passages. They mix with 
the respiratory murmur, and obscure it, or 
completely replace it. We divide them into 
two groups: the first called dry, or vibrating, 
because they consist only of variable sounds; 
the others humid, or blebby, because they 
are caused by blebs. 

1st. Vibrating Rattles. — We comprehend un- 
der this name the two principal varieties of 
the sonorous rattle, the acute or sibilant so- 
norous, and the grave or snoring sonorous. 
The first consists of a whistling, more or less 
acute; the second is characterized by a graver 
musical sound, which resembles the snoring 
of a man asleep, or, rather, the sound which 
a base chord gives under the finger. Often 
united, at times they alternate and displace 
each other. 



24 AUSCULTATION. 

The sonorous rattle may be heard in a 
great number of diseases, such as pulmonary 
emphysema, phlegrnasy, or catarrh of the 
bronchi, and the compression of these con- 
duits by tumors situated within the passage. 
These morbid states are various, but they all 
have a common element, — namely, the mo- 
mentary or permanent contraction of one 
point or another in the air-passages. 

By reason of the frequency of bronchial 
catarrhs, and the comparative rareness of 
other morbid conditions, in which snoring 
or whistling can manifest themselves, the so- 
norous rattle announces almost certainly a 
state of inflammation, or of fluxion in the 
bronchi. 

2d. Blebby Rattling. — This comprehends the 
crepitating, the subcrepitating, and the cav- 
ernous. 

A. Crepitating Rattle. — The crepitating or 
vesicular rhonchus presents to the ear the 
sensation of a fine and dry crackling, analo- 
gous to the sound which is produced by salt 
when made to crackle by a gentle heat in 
a basin, or to the sound which is heard on 
pressing between the fingers a lamina of 
aerated lung. Its blebs, perceived exclusively 
in inspiration, are very small, very numerous, 



RATTLING. 25 

equal in volume, and a little dry. Its seat of 
predilection is the posterior and inferior part 
of the chest, on a single side. 

The crepitating rattle is found in pneumo- 
nia, in certain forms of pulmonary conges- 
tion, in oedema, and in apoplexy of the lung. 

By reason of the extreme frequency of in- 
flammation of the lung, opposed to the com- 
parative rarity of oedema and of apoplexy, 
the crepitating rhonchus — above all, when 
its characteristics are very decided — is the 
almost pathognomonic symptom of pneumo- 
nia, at the period of choking (engouement). 

B. Subcrepitating Battle (mucous, bronchial, 
humid). — The subcrepitating has been justly 
compared to the sound which is perceived 
by blowing with a straw into soapsuds. The 
varying volume of its blebs must distinguish 
it into fine, middling, and coarse subcrepi- 
tating; the number of the blebs and their 
character are equally variable. The rattle 
accompanies both inspiration and expiration, 
and its place of election is the inferior and 
posterior part of the chest, on both sides. 

The subcrepitating rattle maybe perceived 
in a number of diseases, such as bronchitis 
in the second stage, different kinds of catarrh 
of the pulmonary mucous membrane, the 



26 AUSCULTATION. 

dilatation of the bronchi with supersecretion, 
certain forms of pulmonary congestion and 
apoplexy, and phthisis at the beginning of 
the softening of the tubercles. 

Of all these affections, the two most fre- 
quent are bronchitis, and tubercles at the 
beginning of the softening stage. The mani- 
festation of the subcrepitating rattle will 
cause us then to think first of those two dis- 
eases, and it is the knowledge of the seat of 
predilection of the rhonchus which will guide 
the diagnosis. If the blebs, being very nu- 
merous at the base of the two lungs, diminish 
as the ear of the observer approaches the top 
of the chest, the existence of bronchitis is al- 
most certain; if, on the contrary, being absent 
or scarce at the base of the thorax, they are 
heard above, especially on a single side, and 
become more and more evident and numer- 
ous as we rise in auscultating, we must diag- 
nosticate tubercles at the softening stage. 

In certain cases of bronchitis complicated 
with pleurisy, accompanied by compression 
of the more flexible parts of the lung, the 
humid rattling, perceived at the middle and 
posterior regions of the chest, assumes some- 
times the character of a true gurgling, capa- 
ble of making us infer serious lesions, bat 



RATTLING. 27 

which disappears by degrees without leaving 
any traces. In other analogous cases, with 
more considerable pressing back of the lung, 
there is heard at times under the clavicle a 
humid rattle with great blebs, which would 
cause us to believe in the presence of pul- 
monary cavities, but which depends in reality 
only on bronchial mucus collected in the 
branches of the superior lobe. 

C. Cavernous Rattle (gurgling). — This rattle 
is formed by blebs, very numerous, large, 
and unequal, and mixed with cavernous res- 
piration; it is this mixture which forms its 
distinctive character. Perceived in inspira- 
tion and. expiration, it is generally circum- 
scribed at the top of one of the two lungs. 
Sometimes the rhonchus, while seated in the 
superior portion of the chest, has very small 
blebs, with a clearer tone, unmixed with 
cavernous respiration. This is the cavern u- 
lous rattle. 

The cavernous rhonchus announces the ex- 
istence of a pulmonary excavation, or of a 
neighboring abscess, communicating with the 
bronchi, or, perhaps, bronchial dilatation. If 
it coincides with the cavernous voice and has 
its seat at the apex of the lung, it is the almost 
certain indication of tuberculous excavation. 



28 AUSCULTATION. 



APPENDIX. 

There are still several anomalous sounds 
different from the preceding, and giving to 
the ear the sensation of rubbing, of a plaintive 
cry, or of the clapping of a valve. These phe- 
nomena, which are rare, are generally con- 
nected with pulmonary excavations. 

A final sound, much more important, con- 
sists of a series of small crepitations, at first 
dry, afterwards humid, and which, being 
generally perceived at the top of the chest, 
are one of the most characteristic symptoms 
of tubercles about to soften. 



.AJRT. IX. 
AUSCULTATION OP THE VOICE. 

If we auscultate upon the larynx of a per- 
son speaking, the vocal sounds resound with 
noise under the stethoscope, and strike the 
ear w T ith force. Along the trachea this reso- 



AUSCULTATION OF THE VOICE. 29 

nance is a little less grave and less intense, 
and upon the chest we hear only a confused 
hum (bourdonnement). The natural resonance 
of the voice which represents exactly all the 
varieties of the voice itself, is as much more 
intense as the latter is stronger, and more 
sonorous, as w T e auscultate nearer the great 
bronchial tubes, and as the chest is larger 
and its w T alls more thin; equal on both sides 
in corresponding points, it is a little more 
marked towards the apex of the right lung, 
because of the greater diameter of the princi- 
pal bronchial tube upon this side. 

In the pathological state at times the vocal 
resonance is only exaggerated, again it suffers 
at the same time modifications in nature, and 
the voice becomes bronchial, tremulous, cav- 
ernous, amphoric. 

A. The exaggerated resounding of the voice, or 
slight bronchophony, is characterized by a res- 
onance of the voice a little stronger than is 
natural, and it is only one degree less than 
the bronchial voice, true bronchophony. It 
is connected w T ith changes generally similar 
but less extensive or less marked. 

B. The bronchial voice is a resonance much 
stronger than is normal; it is remarkable for 
its intensity, its extent, its fixedness, its per- 

3* 



30 AUSCULTATION. 

manence. It almost always coincides with 
the bronchial respiration. It maybe verified 
in dilatation of the bronchi, in pleurisy, and 
above all in induration of the lung. But on 
account of the rarity of dilatation of the 
bronchi, it is almost always pulmonary in- 
duration which is announced by bronchoph- 
ony. Now of all the changes in which the 
density of the lung is augmented, pneumonia 
and tubercles are incomparably the most fre- 
quent. The conditions of the bronchial voice 
being better fulfilled in pneumonia than in 
tubercles, this voice is more decided in the 
former disease than in the latter; it scarcely 
exists except in certain cases of pleurisy, and if 
at that time it is strong and extensive, we may 
infer that the pleuritic effusion is complicated 
by pneumonic or tuberculous induration. 

C. The tremulous voice (regophony) is a pecu- 
liar resonance when the voice takes a harsher 
tone, and becomes more tremulous and jerky. 
At times it sounds as if the patient spoke 
with a counter placed between the teeth and 
the lips (Polichinello voice). It is usually 
heard on a single side in the inferior half of 
the infra-spinata fossa, and when it occupies 
a more considerable extent, it is in this point 
still that it is the most decided; it may change 



AUSCULTATION OF THE VOICE. 31 

its seat in different positions of the patient. 
It coincides almost always with the weakness 
or absence of the vesicular murmur at the 
base of the chest. 

True segophony announces a pleural effu- 
sion, which is almost always serious. If it 
is perceived on one side alone, with coinci- 
dence of fever, there is pleurisy ; if on both 
sides, without fever, and with general dropsy, 
there is hydrothorax. If it appears in the 
course of a phlegmasy of the pulmonary pa- 
renchyma, and if besides, it changes its place 
as the patient changes his position, it indi- 
cates pleuro-pneumonia. 

D. The cavernous voice (pectoriloquy). — The 
voice is cavernous, if it seems to us, in aus- 
cultating a speaking patient, that the vocal 
vibrations are concentrated into a hollow 
space, whose walls return the sounds to the 
ear, more or less distinctly articulated. 

It is generally circumscribed at the supe- 
rior part of the chest, and coincides either 
with the cavernous rattle, or, especially, with 
cavernous respiration. 

Cavernous voice, like cavernous breathing, 
indicates the existence of bronchial dilatation 
of tuberculous, purulent, apoplectic, or gan- 
grenous excavation. 



82 AUSCULTATION. 

From the rarity of bronchial dilatations, 
and of pulmonary excavations, independent 
of phthisis, compared to the frequency of 
caverns in consumptive patients, we con- 
clude that nine times in ten, cavernous voice 
aim ounces tuberculous excavation. 

E. Amphoric voice is characterized by a res- 
onance entirely similar to the metallic and 
cavernous hum which is produced in speak- 
ing through the neck of a great pitcher three- 
quarters empty. It usually coincides with 
amphoric respiration, and announces, like 
it, pneumothorax, and more rarely, a vast 
pulmonary excavation. 



JLIRT- III. 
AUSCULTATION OF THE COUGH. 

If the ear be applied to the chest of a 
healthy man, we perceive when he coughs, 
a dull and confused sound, accompanied by 
a concussion which shakes the pectoral cav- 



AUSCULTATION OF THE COUGH. 33 

ity. This phenomenon, compounded of im- 
pulsion and of noise, is more perceptible as 
it passes nearer the ear, and in the more vo- 
luminous bronchial tubes, and when the pa- 
tient coughs with more force. The cough 
heard upon the larynx and trachea, and, in 
subjects with a narrow chest, at the root of 
the bronchi, is somewhat cavernous, and gives 
the sensation of the rapid passage of air into 
a tube. In the pathological state, the cough 
offers especial characteristics ; it is bronchial 
or tubal, cavernous, amphoric. 

When the cough is tubal, the ear feels the 
sensation that would be given by a column 
of air, traversing with much noise, force, and 
rapidity, tubes with solid sides. It shows 
itself under the same conditions as bronchial 
respiration, and above all, is connected with 
pulmonary hepatization. 

The cavernous cough consists of a reso- 
nance, stronger and especially more hollow 
than that of the normal cough. It is accom- 
panied by an impulsion against the ear which 
is entirely characteristic. It is one of the most 
positive symptoms of a pulmonary cavity. 

The amphoric cough is characterized by 
a very distinct metallic resonance ; it an- 
nounces, when joined to the amphoric respi- 



34 AUSCULTATION. 

ration and voice, the existence of pneumo- 
hydrothorax, or of a vast pulmonary excava- 
tion. 



METALLIC TINKLING. 

This name is given to a little silvery sound, 
single or multiplied, similar to the sound 
which is produced by letting one or more 
grains of sand fall into a metallic cup. It 
accompanies the respiration and voice, but it 
is generally more distinct during the cough. 
It announces the existence either of a very 
great pulmonary cavern, or of pneumothorax, 
or of hydropneumothorax, with or without 
fistulous perforation of the bronchi. 

Because of the rarity of caverns sufficiently 
spacious to cause this phenomenon, the me- 
tallic tinkling, when it is well marked, is 
almost always the. indication of pneumotho- 
rax. As the gaseous effusions of the pleura 
rarely exist without liquid collection, or with- 
out pulmonary perforation, if the tinkling is 
produced constantly and distinctly, by respi- 
ration and by the voice, it is a pathognomoni- 
cal symptom of hydropneumothorax, with 
fistulous communication of the pleura and 
bronchi. 



AUSCULTATION OF THE LARYNX. 35 



SOUND OF THOEACIC FLUCTUATION. 

In the physiological state succussion causes 
no noise in the chest ; it is the same in sim- 
ple liquid effusion of the pleura ; but when 
there is a simultaneous collection of liquid 
and of air, the collision of these fluids, deter- 
mined by blows upon the trunk, or by the 
spontaneous motions of the patient, causes the 
ear to hear a rattling perfectly like the sound 
produced by shaking a decanter half full of 
water. At times this phenomenon is so de- 
cided that we hear it at a distance ; it almost 
always accompanies amphoric respiration and 
metallic tinkling, and it indicates, like them, 
the existence of pneumothorax, or of a very 
large pulmonary cavern half full of liquid. 



AUSCULTATION OF THE LARYNX. 

In the normal condition, in the larynx, the 
respiratory sound has a hollow and cavernous 
tone, the vocal resonance is at its maximum, 



36 AUSCULTATION. 

and the cough gives the sensation of the rapid 
passage of air through a hollow space. 

In the pathological condition, the laryngeal 
respiratory murmur is more harsh, more rasp- 
ing, as in the case of acute or chronic laryng- 
itis; or indeed it is replaced by a whistling, 
in spasm or oedema of the glottis, in stridu- 
lous laryngitis, and in some cases of foreign 
bodies, and of compression of the trachea; or 
by a sonorous cry in cases of laryngeal ulcera- 
tions with decided tumefaction of the edges 
and obstacle to the passage of air, or still again 
by a snoring in simple or stridulous laryng- 
itis, in ulcerations, laryngeal vegetations, etc., 
a snoring which in croup, has often a metal- 
lic tone. 

In some circumstances, the ear perceives a 
cavernous laryngeal rattling, when, for ex- 
ample, the trachea and the larynx are filled 
with mucosities; this rattle may be more cir- 
cumscribed and be connected with the pres- 
ence of mucosities upon an ulceration or 
around a foreign body, arrested in the ven- 
tricles, etc. Finally, in rare cases, we per- 
ceive a tremulousness (tremblotemenf), which 
announces the existence of croup, with false 
floating membranes. 

There is another symptom which is met 



AUSCULTATION OF THE LARYNX. 37 

with in a great number of diseases of the 
larynx, which although verified by auscul- 
tation of the chest, ought to be mentioned 
here; it is the diminution or complete aboli- 
tion of the vesicular murmur. This phe- 
nomenon is connected with every alteration 
which introduces a notable obstacle to the 
introduction of air into the air-passages, 
whether it obstructs or contracts the diame- 
ter of the conduits (swelling, pseudo-mem- 
branes, vegetation, accidental productions, 
foreign bodies, etc.), whether it compresses 
them from without inward (cancerous tu- 
mors, cysts, aneurisms, etc.), finally whether 
it produces more or less complete occlusion 
of the superior orifice of the aeriferous tube 
(hypertrophy of the tonsils, polypus of the 
nasal fossae falling back on the superior part 
of the larynx, etc.). 



38 AUSCULTATION. 

Chapter II. 

gurstultation of % Circulatorg gigparatttg. 

This comprehends the auscultation of the 
heart, and of the great vessels. 



J^JEIT. IE- 
AUSCULTATION OF THE HEAKT. 

\ 1. Physiological Phenomena. 

In the natural condition, if we apply the 
ear to the precordial region, we hear a 
species of tick-tack, composed of two succes- 
sive sounds, which are regularly repeated 
sixty to eighty times a minute. 

The first of these sounds, dull, profound, 
and more prolonged than the second, coin- 
cides with the striking of the point of the 
heart against the thorax, and immediately 
precedes the radial pulse; it has its maxi- 
mum of intensity between the fourth and 
the fifth rib, below and a little outside of the 
left nipple. The second, clearer, shorter, and 



PHYSICAL PHENOMENA. 39 

more superficial, takes place after the pulsa- 
tion of the arteries, and its maximum of in- 
tensity is nearly at the level of the third rib, 
a little below and to the right of the nipple. 

Considered in their rhythm, the sounds 
are repeated in the following order : at first 
the dull sound, then the small silence, after- 
wards the clear sound, and finally the great 
silence; every pair, with the intermediate 
silences constitutes a complete beat. The 
beats, numbering from sixty to eighty in the 
adult, are more frequent in infancy ; and are 
also accelerated by exercise, the moral emo- 
tions, etc. The force of the sounds varies 
according to the energy and rapidity of the 
contractions of the heart, and the idiosyn- 
crasy of individuals, and the physical disposi- 
tion of the thorax : they are more intense in 
nervous subjects, with narrow and thin chests, 
etc. Their extent is equally variable : dis- 
tinct in the precordial region, they weaken 
by degrees as w r e remove from this centre ; 
they are still perceived with considerable fa- 
cility, on the right side in front; they are less 
so on the left side at the back, and with diffi- 
culty on the right side posteriorly. They 
vary also in extent according to the condition 
of the surrounding organs, which conduct the 



40 AUSCULTATION. 

sounds with greater or less facility. Their 
tone offers several different shades ; but they 
are otherwise clear, and present nothing 
harsh or rasping to the ear. 

The mechanism of these sounds has been 
explained with much diversity. Here are the 
conclusions to which reason and experiment 
have guided us, and which cardiography has 
put beyond all kind of doubt. 

The series of movements of the heart be- 
gins with the contraction of the auricles; 
immediately after comes the contraction of the 
ventricles, to which succeeds their diastole. 

The shock of the heart, and consequently 
the dull sound, coincide with the ventricular 
contraction and the diastole of the great arte- 
ries ; the second sound corresponds with the 
dilatation of the ventricles and with the sys- 
tole of the arteries near the heart. 

The first sound is produced at once by the 
muscular contraction of the ventricles, by the 
shock given to the inferior face of the sig- 
moidal valves, and to the pulmonary and 
aortic base of the sanguineous columns by the 
clapping of the auriculo-ventricular valves, 
and by the impulsion of the point of the heart 
against the thorax. 

The second sound is due above all to the 



CHANGES OF SEAT. 41 

clapping of the sigmoidal valves, and to the 
shock in return, upon their concave face, of 
the sanguineous columns thrown into the 
aorta and the pulmonary artery. 

\ 2. Pathological Phenomena. 

In the morbid state, the sounds present 
various alterations, as regards their seat, their 
extent, their intensity, their rhythm, and their 
tone ; they may also be preceded, accompanied, 
followed, or replaced by anomalous sounds. 

1st. Changes of Seat. 

Sometimes the sounds of the heart are dis- 
placed, and their maximum no longer cor- 
responds with the points that we have indi- 
cated. These displacements may depend on 
lesions of the heart, of the pericardium, of the 
great vessels, or of the surrounding organs. 

The depression of the two sounds may be 
due to tumors situated at the base of the 
heart, and which depress it, or to hypertrophy 
with dilatation of the auricles; their elevation, 
to the diaphragm being pressed back from 
below upwards; their lateral displacement, 
to liquid or gaseous effusions in the pleura; 
their displacement backwards to tumors of 

4* 



42 AUSCULTATION. 

the anterior mediastinum. Morbid adhesions 
of the heart to the pericardium, rickety de- 
formities of the thorax, general or partial 
hypertrophies, may also displace the sounds 
in different ways. 

2d. Changes in Intensity and Extent. 

In certain circumstances the sounds of the 
heart are only heard in the precordial region, 
and besides are scarcely appreciable, so weak 
are they or so badly transmitted to the ear. 
At other times, on the contrary, they are 
strong and loud ; the ear, raised to the region 
of the heart by the energetic contractions of 
that organ, perceives the two sounds very dis- 
tinctly at all points of the thorax, at times 
even at a distance, so great is their intensity, 
or so perfect is their transmission. 

A diminution in the extent and force of the 
sounds may depend on atrophy of the heart, 
on concentric hypertrophy, on softening, or 
on a condition of local atony or of general 
weakness, or yet again on the existence of an 
effusion in the pericardium, or on emphysema 
of the anterior edge of the left lung. 

An increase of the extent and force of the 
sounds will depend, either on hypertrophy 



CHANGES IN RHYTHM. 48 

with dilatation of the cavities of the heart, or 
on induration of the muscular tissue of its 
walls, either on nervous palpitations, on a 
state of general morbid excitability, or indeed 
on changes of the neighboring organs, such 
as pulmonary hepatization, tubercles, etc, 

3c?. Changes in Rhythm. 

The sounds of the heart may be changed in 
their frequency, in their order of succession, 
and in the number of sounds which corres- 
pond with each beat. 

Without speaking of the febrile state, in 
which the frequency of the pulsations may 
rise to 140 or 150 in a minute, there are cer- 
tain grave affections of the heart in which 
they exceed this number ; and sometimes they 
are so much precipitated that they can no 
longer be counted. As for the slackening of 
the pulsations, whose number may descend 
as low as 30, 20, and even 16, it is connected 
either with certain diseases of the encephalo- 
spinal system, or especially with the action of 
digitalis ; it has likewise been noticed in cases 
of alteration of the aortic orifice, at times with 
softening or fatty degeneracy of the heart. 
The order of succession may be disturbed in 



44 AUSCULTATION. 

very different ways : sometimes the beats are 
precipitated and retarded alternately; some- 
times they experience, at intervals, a stop 
whose duration equals that of an entire beat: 
this constitutes an intermission; — these dis- 
orders have not in themselves a very exact 
morbid significance. But at other times, the 
irregularity is such that the confused and tu- 
multuous beats no longer preserve any meas- 
ured time, and when this fact is permanent, 
it is rather the indication of various physical 
changes of the heart, among which comes 
in the first rank contraction of the mitral ori- 
fice. 

At times, again, the disturbance is limited 
to one of the elements of the beats ; thus, one 
of the silences (usually the great one) is more 
prolonged, which may depend on the diffi- 
culty that the blood finds in penetrating into 
the ventricles, when there exists an auriculo- 
ventricular contraction ; or the prolongation 
affects one of the sounds (generally the first), 
as we observe in cases of hypertrophy with 
contraction of the arterial orifices. 

As to the number of the sounds, sometimes 
one alone is perceived, as when the first is so 
much prolonged as to cover the second, which 
is scarcely observed except in cases where it 



CHANGES IN CHARACTER. 45 

is transformed into an anomalous sound; at 
times, on the contrary, three sounds are 
heard: this phenomenon has been met with 
in some cases of contraction of the orifices ; 
it has been thought that it might be attributed 
at other times, to the addition of a clapping 
produced by the hypertrophied auricle whose 
contractions are aphonous in the natural state; 
we have also noted a doubling of the second 
sound towards the close of some cases of 
pericarditis. The formation of four sounds 
is also connected with certain organic affec- 
tions with contraction of the orifices. Finally, 
it is generally recognized that the cause of 
triple and quadruple sounds is a defect of 
synchronism in the motions of the right and 
left hearts, and oftener still they result from 
the addition of anomalous sounds. 

4th. Changes in Character. 

The sounds suffer many changes in relation 
to their tone ; they are more clear or more 
dull than in the natural condition. The clear 
sounds Tivdj be referred to a thinning of the 
walls of the heart; the dull character of the 
sounds announces, on the contrary, a thicken- 
ing of the valves, and oftener a hypertrophy 
of the walls themselves. 



46 AUSCULTATION. 

Some dry and hard sounds have seemed to 
coincide at times with a certain degree of 
thickening and rigidity of the valves; hoarse 
and deadened sounds have appeared to refer 
rather to a condition of softness or of expan- 
sion of these membranous veils. 

The metallic tone {metallic tinkling of the 
heart), may depend on nervous palpitations, 
or on a gaseous distension of the stomach; it 
is connected at times with an induration of 
the ventricular walls, and in very rare cases, 
it may be due to the presence of pneumotho- 
rax. 

Further, the sounds of the heart may lose 
their clearness, and become a little blowing 
or rasping. These changes in character sig- 
nalize the first degree of various lesions in 
the valves and the orifices, lesions whose ex- 
istence, in a more advanced stage, will be 
revealed by anomalous sounds. 

bth. Anomalous Sounds of the Heart. 

Anomalous sounds, that is those of which 
there exists no trace in the physiological con- 
dition, are divided into two kinds : the souuds 
of blowing or souffle, which are produced 
in the cavities of the heart themselves, and 






SOUNDS OF SOUFFLE. 47 

the sounds of friction, which are formed out- 
side of that organ, in the pericardium. 

First Kind — Sounds of Souffle. 

Under this denomination are comprehended 
the souffle properly speaking, or soft souffle, 
the sounds of the rasp, file, or saw, and finally 
musical sounds, such as whistling, whining, 
etc. 

A. Sound of Souffle (Bellows Sound). — Of all 
the anomalous sounds this is the most com- 
mon ; its name itself is the best definition. 
More or less sweet to the ear, it is single or 
double, that is to say it can be perceived 
during the systole or diastole alone, or during 
both. 

We meet the sound of souffle, 1st. In a 
great number of diseases with physical le- 
sions of the heart, contractions of the orifices, 
changes in the valves (fibrinous deposits, vege- 
tations, insufficiency, etc.); hypertrophy, with 
dilatation, endocarditis, etc. ; 2d. In diseases 
with alteration of the blood (anemia, chloro- 
sis) ; 3d. In diseases with nervous disturb- 
ance of the heart (palpitations, etc.). 

If the sound of souffle shows itself in af- 
fections so numerous and so different, what 



48 AUSCULTATION. 

shall we do in order positively to understand 
its morbid signification? The problem to 
be first solved, is the following: A sound of 
cardiac souffle being given, is there or is 
there not organic lesion of the heart ? In or- 
der to answer this first question, we must 
study by turns the tone of the sound, the 
time at w T hich it shows itself, its persistence, 
its progress, and finally the whole of the con- 
comitant phenomena. 

The souffles which are connected with or- 
ganic lesion of the heart, at times soft to the 
ear, are more often harsh, and approach the 
sounds of the rasp, the file, etc. On the con- 
trary, the souffles in the absence of material 
lesions, are almost always very soft. The for- 
mer accompany the first or second period of 
the heart; the latter are always in the first 
period, and never in the second. The former 
being permanent, last for months or years ; 
the latter are generally intermittent and fleet- 
ing. In time, as the lesions of the orifices be- 
come graver and more profound, the former 
suffer gradual transformations from the soft 
souffle to the musical sounds ; the latter habit- 
ually preserve their character of softness, what- 
ever maybe their modifications of intensity. 

Finally, some are accompanied by local and 



SOUNDS OF SOUFFLE. 49 

general symptoms characteristic of an affection 
of the heart; dulness, the purring tremor (fre- 
missement cataire), irregularities of the pulse, 
considerable oedema of the inferior extremi- 
ties, whilst none of these phenomena are seen 
in chlorosis or anemia, at least in a decided 
and durable manner. 

To resume — the soft tone of the sound, its 
exclusive connection with the first period of 
the heart, its intermittence or its short dura- 
tion, and the absence of a certain number of 
grave phenomena, — such are in general the 
characteristics of the souffle, which is inde- 
pendent of a physical lesion of the heart, 
whilst the souffle that indicates a material 
alteration of the organ usually has the oppo- 
site characters of harshness, of coincidence 
with the two periods, or with the second 
alone, of permanence, and of combination 
with other morbid conditions. 

The existence of a physical lesion being ad- 
mitted, the next point is to discover what is 
its nature. Now, the souffles which depend 
on pericarditis, on hypertrophy, on the for- 
mation of a clot in the cavities of the heart, 
are accompanied by particular signs, such as 
hollowness and dulness at the precordial re- 
gion, diminution in the stroke, with weak- 
5 



50 AUSCULTATION. 

ness and distance of the sounds (pericarditis), 
dulness, increase of intensity of the sounds 
and of impulsion (eccentric hypertrophy), sud- 
den manifestation of the anomalous sound, 
weakness of the arterial pulse (formation of 
clots). These lesions being removed from the 
diagnosis, there remains scarcely anything but 
the diseases of the orifices, and of the valves, 
and from the point of view of their principal 
effects, the latter may be arranged into two 
classes, contractions and insufficiencies. 

How shall we discover whether there is 
contraction or insufficiency ? In order to an- 
swer this question, we must first discover the 
period to which the anomalous sound belongs, 
to determine whether it precedes or accompa- 
nies the systole, or whether it coincides with 
the diastole of the heart, and the morbid sig- 
nification of the souffle may be deduced by 
representing to oneself the acts which corres- 
pond with each of these motions. 

If the morbid sound precedes the first nor- 
mal sound of the heart, it takes place at the 
moment of the contraction of the auricles, 
and depends on an obstacle to the free pas- 
sage of blood into the ventricles ; the presys- 
tolic souffle is then the indication of a con- 
traction of the auriculo- ventricular orifices. 



SOUNDS OF SOUFFLE. 51 

If the anomalous sound coincides with the 
first sound, it corresponds to the systole of 
the ventricles, and may be due either to an 
obstacle which impedes the direct course of 
the blood through the aortic or pulmonary 
openings, or to some morbid condition which 
facilitates the reflux of this liquid into the 
auricles; the systolic souffle may then indi- 
cate either a contraction of the arterial ori- 
fices, or insufficiency of the auriculo-ventric- 
ular openings. 

Finally, if the anomalous sound exists at 
the second period, it corresponds to the dias- 
tole of the heart, and is connected, in the im- 
mense majority of cases, with reflux of the 
blood into the ventricles; consequently, the 
diastolic souffle announces almost always an 
insufficiency of the sigmoid valves. 

In cases of doubt, and especially of souffle 
at the first period, the exact pointing out of 
the diseased orifice will indicate the nature 
of the existing lesion. 

If we specify that there exists, for example, 
a lesion of an arterial orifice, in a case where 
the souffle replaces the first sound of the 
heart, we shall consequently have diagnosti- 
cated an arterial contraction. 

Now the seat of the disease will be recog- 



52 AUSCULTATION. 

nized by understanding the spot at which is 
produced the maximum of the souffle, and 
by this consideration — that it is transmitted 
to the great vessels, or that it does not ex- 
tend beyond the region of the heart. In 
effect, the souffle due to lesion of the sigmoid 
valves has its maximum of intensity above 
the nipple, at the base of the heart, and is 
transmitted more or less to the great arteries, 
while the souffle due to an alteration of the 
auriculo-ventricular valves has its maximum 
below the nipple, nearer to the point of the 
heart, and is not transmitted to the great ar- 
terial trunks. 

If, then, the souffle at the first sound has 
its maximum of intensity at the base of the 
heart, and is transmitted to the great arteries, 
it will be the indication of arterial contrac- 
tion. This same souffle at the first sound, 
having, on the contrary, its maximum at the 
point of the organ, without transmission to 
the great arterial trunks, will indicate auric- 
ulo-ventricular insufficiency. Let vis recol- 
lect here, that while recognizing that a 
souffle belongs to the first period of the heart, 
it is often very difficult to determine ex- 
actly whether it precedes, accompanies, or 
immediately follows the systole ; we are then 



SOUNDS OF SOUFFLE. 53 

obliged, in order to judge of its value, to 
discover whether it is transmitted to the 
aorta, or whether it remains circumscribed 
at the precordial region. In the first case it 
indicates a lesion of the aortic orifice, which 
is always a contraction ; in the second, this 
souffle at the first period of the heart signi- 
fies an alteration in the auriculo-ventricular 
orifice, which may be contraction of its con- 
tour or insufficiency of its valve. 

As for the souffle at the second sound, as 
it is most frequently produced at the level of 
the arterial orifices, and almost never at the 
level of the auriculo-ventricular openings, we 
should, from the single fact of its presence, 
infer a change in the sigmoid valves; and 
if it be proved that it is transmitted to the 
great arteries, we cannot doubt that there is, 
in effect, arterial insufficiency. It follows 
that the diastolic souffle will very rarely be 
the indication of auriculo-ventricular contrac- 
tion, and the latter lesion will be better recog- 
nized, as we have said, by the presence of 
presystolic souffle. Let us add, that very 
often this contraction is not revealed by any 
appreciable morbid sound. 

After having determined the kind of dis- 
eased orifice, and the species of lesion by 



54 AUSCULTATION. 

which it is affected, there remains only to 
decide whether the alteration belongs to the 
right or to the left heart. We shall ar- 
rive at the solution of this problem by exam- 
ining the relative seat of the anomalous sound 
of one half of the heart in comparison with 
the normal sounds of the other half. We 
know that conditions capable of producing 
souffles reside in both sides, and that thus 
one of the two sounds may be changed in 
the left heart and remain normal in the right 
heart, and reciprocally. If, then, for example, 
we heard on the left of any point whatever 
the maximum of an anomalous sound, whilst 
more to the right we found again the natural 
sound, we must conclude that the lesion and 
the souffle which reveals it belong to the left 
heart, and vice versa. 

Besides, the diagnosis of diseases of the left 
cavities will be better confirmed by the ex- 
istence of changes in the pulse, and that of 
affections of the right cavities, by disturb- 
ances in the circulation of the great veins, 
and especially of the jugulars. 

Until this time we have supposed that 
there existed a single souffle in the precordial 
region. Now let us admit that it may be 
double; this will indicate either a lesion of 



SOUNDS OF SOUFFLE. 55 

two orifices, or a double lesion of the same 
opening, and the same considerations drawn 
from the seat of the souffle, from its propaga- 
tion, etc., will still serve to determine what 
kind of combined lesions exists. 

Let us add, besides, that the diseases of the 
valves which bring on contraction (such as 
thickening, induration of these membranous 
veils) are also often of a nature to cause their 
insufficiency. We must then conclude that 
a double sound of souffle will rather be the 
indication of a double lesion of a single ori- 
fice than of two lesions, the one seated at an 
arterial orifice, the other at an auriculo-ven- 
tricular orifice; and as the auriculo-ventricu- 
lar contraction often exists without noise, the 
result is that a double anomalous sound, con- 
sidered independently of the other elements of 
the diagnosis, will sooner indicate arterial con- 
traction and insufficiency than any other kind 
of combined alteration; besides, as the dis- 
eases of the valves are much more frequent 
on the left than on the right, a double sound 
of souffle will usually announce contraction 
of the aortic orifice with insufficiency of the 
sigmoid valves. 

B. Sounds of the Rasp, File, and Saw. — These 
anomalous sounds, which their name describes 



56 AUSCULTATION. 

with sufficient exactness, often replace the 
first sound of the heart; at times they are 
double, and cover the second as well as the first 
sound. They are permanent, and generally 
never disappear after they are well establish- 
ed; it is more common to find them, on the 
contrary, transformed afterwards into musi- 
cal sounds. They are almost always accom- 
panied by a vibratory shuddering, purring 
tremor, perceptible to the hand. 

They announce almost constantly organic 
changes of the orifices of the heart, and more 
frequently contractions than insufficiencies. 
Their character of harshness indicates, in gen- 
eral, a greater friction, and consequently more 
decided lesions than those which are pointed 
out by simple sounds of souffle; these are 
generally cartilaginous or osseous indura- 
tions, calcareous deposits, etc. 

C. Musical Sounds, Whistling, Whining (piaide- 
ment). — These are sounds compared to whis- 
tling, cooing, or to the sibilant rattle of bron- 
chitis. Most frequently these sounds are but 
the more elevated degree, the more acute 
tone of the sounds of souffle, and indicate 
nearly the same physical conditions in their 
extreme stage. In effect, they are connected 
with profound lesions of the valves, and prin- 



SOUNDS OF FRICTION. 57 

cipally with considerable contractions of the 
aortic orifice, caused by calcareous deposits, 
and by the ossiform degeneracy of the sig- 
moid valves. 

The musical sounds of the heart have been 
verified exceptionally, in simple hypertro- 
phies with dilatation of the ventricular cavi- 
ties. They may even be produced indepen- 
dently of every physical lesion of the organ, 
in changes of the blood, such as chlorosis; 
but it is when this affection is superimposed 
on a valvular lesion, that it will especially 
tend to give the musical character to a car- 
diac souffle. 

Second Kind — Sounds of Friction. 

Pericardic Friction, — Under the generic 
name of sound of friction of the pericardium 
are designated several phenomena, which 
present considerable analogy to the varieties 
of pleural friction, and which recognize as 
their cause similar anatomical conditions. 
Thus we distinguish a soft friction or grazing, 
and a harsh friction or creaking, like the 
sound of new leather, which imitates the 
creaking of a new sole under the motions of 
the foot; at times it is a scraping, more or 
less analogous to the sound of the rasp. 



58 AUSCULTATION. 

The sound of friction points out either the 
existence of pericarditis with false mem- 
branes, and coincidence of a little liquid, or 
the presence on the anterior face of the heart 
of certain consecutive changes. Grazing de- 
notes that the pseudo-membranous exudation 
is recent, soft, thin, and scarcely rugose. The 
harsh friction (the sound of new leather), an- 
nounces that the pseudo-membranes are older, 
thicker, unequal, resisting. Finally the sound 
of scraping is connected with the formation 
of harder morbid products, such as cartilag- 
inous or osseous plates in the pseudo-mem- 
branes, osteo-calcareous laminae developed in 
the parietal pericardium, or yet again, solid 
concretions lodged among the fibres of the 
heart and making leaps under the serous 
membrane which clothes it. 



-A.IRT. II. 
AUSCULTATION OF THE GKEAT VESSELS. 

Let us study in succession the sounds that 
are furnished by the aorta, the arteries, and 
the veins. 

In the normal state, we hear, under the pas- 



AORTIC SOUNDS. 59 

sage of the thoracic aorta, two sounds which 
the ear cannot distinguish from those of the 
heart, and along the ventral aorta, we per- 
ceive no longer any sound but a single one 
corresponding to the diastole of the vessel. 
On the arteries in the neighborhood of the 
heart, we hear in the same manner two 
sounds; on those which are more distant we 
perceive only a single one, which grows weak 
as we auscultate farther from the centre of 
circulation. Finally, on the veins, the ear 
does not seize the trace of any sound. In the 
pathological condition, anomalous sounds are 
produced in these various parts of the vascu- 
lar system. 



1. AOKTIC SOUNDS. 

In diseases of the aorta, auscultation reveals 
sometimes a single sound, constituted either 
of a sound of souffle, of the rasp, or of the 
saw, or by a rattling more or less prolonged; 
sometimes a double sound analogous to that 
of the heart, or indeed, a double souffle, or 
finally a clapping preceded or followed by a 
souffle. Of these various sounds, some are 



60 AUSCULTATION. 

only the transmission of those which pass in 
the heart; the rest are intrinsic sounds. 

Generally, the morbid sounds are double 
on the thoracic aorta, and simple upon the 
abdominal aorta. They may point out nu- 
merous lesions, either of the orifice of the 
aorta itself, such as contractions or insuffi- 
ciencies; or of the interior of the vessel, such 
as pseudo-membranous, cartilaginous depos- 
its; calcareous, ossiform incrustations; ero- 
sions of the inner coating; contractions; dila- 
tations; aneurismal sacs or varicose aneurisms. 

The symptoms of contractions, and of in- 
sufficiencies of the aortic orifice having al- 
ready been shown, let us here only recall the 
phenomena proper to diseases of the vessel 
itself. 

A harsh souffle, or grating sound, perceived 
exclusively on the passage of the aorta, over 
a great extent, reveals the existence, on the 
internal surface of the vessel, of rugosities 
which depend on recent pseudo-membranes, 
if there is fever; and on cartilaginous or cal- 
careous plates, if there is coincident apyrexia, 
above all in an old person whose radial artery 
presents ossifications. A soft souffle, percep- 
tible over the whole passage of the pectoral 
artery, would rather be a symptom of chloro- 



AORTIC SOUNDS. 61 

anemia, if it coincided with an analogous 
sound in the vessels of the neck. An aortic 
souffle limited to a small extent might make 
us suspect local contraction of the vessel, 
especially if there were simultaneously veri- 
fied energetic pulsations of the arteries spring- 
ing above the constricted portion. 

A sound of souffle or grating perceived at 
the first period, behind the sternum, with 
dulness at the same point and purring tre- 
mor [fremissement cataire), without tumor, 
is the indication of a dilatation of the ascend- 
ing aorta; and if this sound were followed by 
souffle at the second period we might infer 
from it that there is also insufficiency of the 
aortic valves. 

A systolic souffle and a diastolic shudder- 
ing (bruissement) independent of the sounds of 
the heart, which remain natural, would render 
probable the existence of an aneurismal ab- 
scess into which the blood enters, and from 
which it goes out with noise. The diagnosis 
would be more sure if to the stethosopic phe- 
nomena are joined dulness, vibratory shud- 
dering, and impulsion; and there will no 
longer remain any doubt, if w T e see a pulsat- 
ing tumor appear at the same point. A dou- 
ble clapping, analogous to the double sound 

6 



62 AUSCULTATION. 

of the heart, having its maximum of intensity 
on a line with a tumor, agitated by movements 
of less manifest expansion, would give rise to 
the idea of an aneurismal sac filled with clots. 
Finally, an intense prolonged shuddering per- 
ceived independent of the sounds of the heart, 
on one of the points where the aorta is in con- 
nection with the venous system, would an- 
nounce the existence of a varicose aneurism 
of the aorta. 

Upon the ventral aorta the same morbid 
sounds (generally simple), such as single ex- 
aggerated beating, the sound of souffle or of 
the rasp, shuddering (bruissement), will have a 
similar pathological signification, as far as 
they coincide with the other phenomena men- 
tioned above. 

Finally, there is found at times upon the 
abdominal aorta an exaggeration of its nor- 
mal beating, without the existence of any 
physical lesion : these beatings reveal the 
morbid state pointed out by Laennec under 
the name of palpitations of the aorta. 

II. VASCULAR SOUNDS. 

The greater part of the anomalous sounds 
produced at the orifice of the aorta, or in its 



VASCULAR SOUNDS. 63 

passage, may be heard even in the arteries 
which spring from it ; but besides these phe- 
nomena of transmission, there are patho- 
logical sounds whose source is in the arteries 
themselves; others are produced more es- 
pecially in the veins; finally, some result 
from the combination of arterial and venous 
sounds. 

A. Arterial Sounds. There is heard over the 
passage of the arteries, at times, an inter- 
mittent souffle, soft to the ear, coinciding 
with the diastole of the vessel, perceived 
most frequently, on many arteries at once, 
but oftenest on the carotids, and more com- 
mon in the right than in the left. At times 
the souffle is more harsh : it is a true rasping 
sound, more rarely generalized, and usually 
accompanied by a shivering perceptible to 
the hand. At other times it is a shuddering, 
more prolonged, more acute, usually limited, 
and coinciding also with a manifest vibratory 
shivering. 

In general the more harsh and circum- 
scribed the sounds are, the more certainly do 
they announce a physical lesion of the ar- 
tery : contractions of its cavity, rugosities of 
its internal surface, aneurismal dilatations, 
compression by tumors, etc. ; — continued 



64 AUSCULTATION. 

shuddering is more particularly met with in 
arteriovenous communications. 

On the contrary the more soft and gener- 
alized are the souffles, the more do they an- 
nounce a change in the entire economy, dis- 
ease of the blood, and particularly, chlorosis 
and anemia. 

B. Vascular Sounds, venous and mixed. The 
sounds that we collect under this title are gen- 
erally continuous, and offer various shades of 
tone and of character. At times it is a dull, 
diffuse murmur, like that which is heard 
when we put to the ear a great univalve 
shell {continuous simple murmur). Sometimes 
it is a more intense murmur, continuous like 
the preceding, but reinforced at each systole 
of the heart, and which gives the sensation of 
two currents running counter to each other 
(sound of souffle with a double current, venous 
hum). Somewhat similar to the sound of the 
bellows of a forge, it becomes at times snor- 
ing and sonorous, so far as to imitate the 
sound produced by whipping a humming-top. 
Finally, at other times there is heard, either 
alone, or combined with one of the two pre- 
ceding varieties, a sibilant and musical noise 
formed of a succession of sounds, diversely 
modulated, and which has been compared to 



AUSCULTATION OF THE ABDOMEN. 65 

the resonance of the diapason, to the vibra- 
tion of a metallic cord {musical sound, song of 
the arteries). 

These three species of sounds are very va- 
riable in their intensity and in their char- 
acter; they modify themselves, increase or 
diminish, by the least change in the tension 
of the parts or under the pressure of the stetho- 
scope. They show themselves principally in 
the vessels of the neck, oftener on the right 
than on the left, and much oftener in women 
than in men. 

These vascular sounds are almost exclu- 
sively connected with diseases of the blood ; 
they are the most certain indication of ad- 
vanced chlorosis and of anemia with notable 
diminution of the sanguine globules. 



Chapter III. 

gutOTlfaiioit of % glbbomm 

In the normal state, in auscultating on 
the abdomen, we hear scarcely anything but 
the sounds of the gases which displace each 

6* 



66 AUSCULTATION. 

other in the digestive tube, and the aortic 
beating already pointed out : the greater part 
of the acts which are performed in the abdo- 
men are not manifested by any appreciable 
sound. In the pathological state, the move- 
ments of the parts covered by the peritoneum, 
which normally take place in silence, may 
produce, when the inflamed peritoneum is 
hung with pseudo-membranes, a sound of 
friction, which is much rarer and weaker than 
the pleuritic friction, and which is scarcely 
produced except on the line of organs of some 
resistance, the liver for example. 

Shocks given to the trunk sometimes pro- 
duce in the stomach a very distinct sound 
of fluctuation in cases of contraction of the 
pylorus. In stricture of the intestine, there is 
also often heard a surging noise (bruit deflot) 
due to the displacement of the liquids and 
gases by the strong contractions of the hyper- 
trophied intestine. A rumbling perceived 
in hernia would announce the existence of 
enterocele. A shivering developed by per- 
cussion in a tumor of the right hypochondriac 
would point out the presence of a hydatid 
cyst. A sound of crepitation produced by 
pressure upon the region of the gall-bladder 
would cause us to suspect an accumulation 



AUSCULTATION OF THE HEAD. 67 

of biliary calculi. Pressure upon the loins 
would perhaps manifest a sound of analogous 
friction in cases of multiple renal concretions. 
In certain voluminous tumors of the kidney 
the production of a metallic tinkling, would 
announce that the cavities of this viscus, 
considerably distended, contained at once liq- 
uids and gases. The presence of one or more 
calculi in the bladder would easily be recog- 
nized by a peculiar rattling produced by the 
blow of the catheter, and transmitted to the 
ear by the stethoscope applied to the pubis, 
or by the probe itself furnished with an acous- 
tic tube. Finally, if we had just distinguished 
double pulsations in a voluminous tumor of 
the lower belly, we should have to conclude 
that there was extra-uterine pregnancy. 



Chapter IV. 

^traultaiiott of % Ipjeafc. 

In auscultating on the head of a person in 
good health, we perceive the respiratory 
sound and the vocal laryngeal resonance 



68 AUSCULTATION. V 

which sound together in the nasal fossse; 
there are also heard the sounds of deglutition, 
of suction, and the transmitted tick-tack of 
the heart. 

The auscultation of the cranium in young 
children, in whom the fontanels are not 
closed, reveals, at times, in the pathologic 
state, a sound of souffle, systolic, soft, almost 
always intermittent, very rarely continuous, 
with or without strengthening (renforcement). 
The cephalic souffle, far from being met with, 
as Messrs. Fisher, of Boston, and Whitney 
pretend, in all cerebral diseases, is found in 
one alone, in chronic hydrocephalus, and then 
in a small number of cases. But it is fre- 
quently met with, like the sounds of the ves- 
sels of the neck, in alterations of the blood ; 
so that if its semeiotic value is null in dis- 
eases of the encephalon, it should, at least, 
be considered as a symptom of anemia, either 
simple or connected with some other affec- 
tion, principally rickets. According to Mr. 
Gendrin, the changes of the arteries, even in 
the interior of the cranium, may be made 
known by anomalous sounds. Finally, ac- 
cording to Dr. Meniere, the introduction of 
air into the cavity of the tympanum produces 
a sound of souffle when this cavity is empty, 



AUSCULTATION OF THE MEMBERS. 69 

a whistling when it is very dry, and a blebby 
rattle when there are liquids which the air 
traverses in passing therein. 



Chapter V. 

gtttstttlfaiicm of i\t pmfors, 

Besides the sounds furnished by the altera- 
tions in the arteries already spoken of, there 
is heard upon certain erectile tumors, a mani- 
fest sound of souffle. The same is the case in 
exophthalmic goitre. 

The sounds that are caused by the striking 
of a probe against a foreign body at the bot- 
tom of a wound, may reveal the nature of 
this body. In certain patients, affected w^ith 
arthritis, the slipping of the opposite articular 
surfaces produces a sound of friction analo- 
gous to that of the pleura. In doubtful cases 
the application of the stethoscope on the place 
of a fracture would allow us to seize, at the 
least motion, a crepitation which might have 
escaped the ear alone, even on much more 
considerable motion. 



70 AUSCULTATION. 

Chapter VI. 
©bsteirical ^rtgtttliafum. 

In pregnancy, after the first half of gesta- 
tion, several sounds are heard, — of which 
one is connected with the circulation of the 
mother {uterine souffle), and the others depend 
on the foetus ; the latter are produced either 
by the beating of the heart of the embryo 
[sounds of the foetal heart), or by its motions in 
the womb (sounds of displacement of the foetus). 
At times again there is perceived a souffle 
synchronical with the foetal pulse, and which 
appears to take place in the cord when this 
vascular body is wound around the neck of 
the foetus, or when only compressed between 
the back of the child and the uterine walls 
(umbilical souffle)) this latter sound is much 
rarer and much less important than the pre- 
ceding ones. 

A. The uterine souffle is a soft souffle, syn- 
chronical with the pulse of the mother, more or 
less prolonged, of a tone sometimes sonorous, 
sometimes more acute, and sometimes even a 
little musical. Heard most commonly about 



OBSTETRICAL AUSCULTATION. 71 

the inguinal regions, it is in the meantime 
movable and may disappear momentaneously 
and be reproduced again without any fixed 
rule. It usually shows itself about the fourth 
month, and beyond the fifth it is rarely want- 
ing. 

As the uterine souffle is a nearly constant 
phenomenon in pregnancy and very rare in 
other conditions, it is a very probable, but not 
a certain symptom of gestation ; and as also it 
is wanting in some cases, its absence is not 
sufficient to exclude the idea of pregnancy. 

B. Sounds of Displacement of the Foetus. — 
Sometimes it is a shock, single or redoubled, 
sometimes a sound of slow and prolonged 
friction, giving the evident sensation of a 
body which is displaced. These phenomena 
generally begin to be perceptible about the 
fourth month, and when they are very mani- 
fest they announce with certainty the exist- 
ence of a living foetus. 

C. Sounds of the Foetal Heart — These are 
double beats, similar to those that are per- 
ceived in auscultating the heart of a newly- 
born child. Habitually about the fifth month 
we begin to hear them ; at first weak, they 
gradually increase in force and are usually 
repeated from 130 to 140 times in a minute. 



72 AUSCULTATION. 

Their frequency and their intensity experience 
also momentaneous variations independent of 
the maternal circulation. 

Their seat corresponds, in different women, 
to various points of the abdomen; besides, it 
often changes in the same woman. But usu- 
ally towards the close of pregnancy the double 
sound becomes more fixed, and it is found 
commonly towards the left iliac fossa. Be- 
sides these momentaneous variations of inten- 
sity and of character, it may, in cases of dis- 
ease of the foetus, be changed into souffle, and 
it ceases definitely on the death of the child. 
As this sign is scarcely ever wanting after 
the fifth month, it has great value. However, 
the absence of double pulsations does not 
prove that there is not pregnancy; it has 
little importance in the four first months; but 
starting from the fifth, every day it fortifies 
more strongly the presumption of the non-ex- 
istence of the foetus, without, however, posi- 
tively establishing it until the term. The pres- 
ence of double pulsations, on the contrary, is 
the surest sign of pregnancy. 

To find them very plainly in two points at 
a distance from each other, would render prob- 
able the existence of double pregnancy, and 
this would be certain if the number of beats 



DYNAMISM. 73 

was always different on the right and on the 
left. 

The distinctness, force, and regularity of 
the sounds announce that the foetus is in 
health; their alteration, their weakness, and 
their intermittence, would reveal that it is in a 
state of suffering or of disease ; finally, the 
increase of these derangements, and the com- 
plete cessation of the double sounds, would 
indicate that the child had ceased to live. 



Chapter VII. 

When with the aid of the dynamoscope we 
auscultate the different parts of the body, we 
hear a dull hum, intermingled with crack- 
lings, and somewhat analogous to the distant 
rolling of a heavy carriage. This sound, in 
the physiological state, presents, according to 
age, and several other conditions of life, dif- 
ferent shades of strength, tone, and charac- 
ter ; it is generally soft, uniform, and perma- 
nent, perceptible on all the regions of the 
trunk and of the members, but always more 

7 



74 AUSCULTATION. 

clearly manifested at the ends of the fingers 
than anywhere else. In the pathological state, 
the murmur (bourdonnemenf), becomes stronger 
and more harsh at the beginning of febrile 
affections. It is weaker on the contrary, in 
the side struck with hemiplegia in a case of 
cerebral hemorrhage. It is null in members 
entirely paralyzed. It often diminishes also 
in the course of acute and chronic diseases ; 
the degree of its weakness is frequently in 
direct ratio to the gravity of the disease, and 
its complete abolition is the indication of ap- 
proaching danger. It almost always ceases 
to be perceived in the fingers five or six hours 
before the death agony. 

The murmur is accelerated in the febrile 
state ; it is unequal, jerky, trembling in the 
paroxysms of pyrexise, and in the attack of 
periodic fever ; in some cases it becomes in- 
termittent, and this change of rhythm is an 
unfavorable symptom, as much more serious 
as the intervals of silence are more pro- 
longed. 

Finally, the murmur may present variations 
of tone and of sound that are frequently met 
with in acute diseases of a grave nature, and 
this dissonant and movable sound is gener- 
alty the indication of great danger. 



DYNAMISM. 75 

But it is from the point of view of the dis- 
tinction between real and apparent death, 
that the exact idea of the murmur (bourdon- 
nement), has its chief importance. In fact, 
as this sound does not disappear entirely until 
twelve or fifteen hours after decease, its per- 
sistence is an indication that organic, life is 
not absolutely extinct; its complete and de- 
finitive cessation is, on the contrary, one 
more sign of the certainty of death, and thus 
dynamism constitutes a means of preventing 
premature burial. 



PERCUSSION. 



The origin of percussion goes back to the 
earliest antiquity. It is extremely probable 
that Hippocrates made use of it in order to 
recognize tympanites.* Ardtee mentions it 
positively when he says : Nam, si prce infla- 
tione, quum verberantur, tympanum quodam modo 
referant, roimw/iaq nominatur.'f Galen also em- 
ployed it to distinguish tympanites from as- 
cites, and from oedema of the abdominal 
walls. J Actuarius also mentions percussion 
in connection with the same disease. § Paul, 

* Aphorisms, sect, iv, aph. 2, coac. 491, 496. 

t De signis et caus. diut. onorb., lib. ii, cap. i, De hydrope ; 
ed. Henr. Stephani, 1567, t. i, p. 36. A little further on he says 
again: " Tympanias autem . . . auditu sonorus est, nam ad 
palinaa percussum abdomen sonum edit." — Ibid., p. 37. 

| " Sed ad veram notitiam comparandam pulsare cogimur ab- 
domen, ut attendamus si veluti tympanum resonet. " — De dlg- 
noscendis pulsions, liber iv, caput iii, Ed. Kuhn, vol. viii, p. 951. 

§".... Qui quum aegri abdomen pulsatur, tympani in mo- 

rem intumescat, Tv/xTraviai dicitur " — De methodo med., 

lib. i, cap. xxi, Ed. Steph., t. ii, p. 164 G. 



PERCUSSION. 77 

of Egina, goes farther, and notes the reso- 
nance of the superior part of the abdomen in 
peritoneal pneumatosis,* and that of the infe- 
rior part in uterine tympanites, f At an 
epoch nearer to our own, the employment of 
percussion often appears in gaseous effusions. 
Tugault applies it to ascites ; J Lazare Riviere 
makes use of it for diagnosis of uterine hy- 
dropsy,§ and of hypertrophy of the spleen. || 
Other authors have also made mention of it. 
However, these are only scattered facts, in- 
complete notions, none of which besides re- 
late to the chest. Nowhere are these ele- 
ments reunited; nowhere are they co-arranged 

* "In qua (affectione) aliquando flatus copia cum paucissima 
humiditate coacervatur, inter membranam peritonaeum apella- 
tam, ac intestina, adeo ut si verberetur superior venter instar 
tympani sonum edat." — De re med., lib. iii, cap. xlviii, Ed. 
Steph., t. i, p. 471 D. 

f " In his sequitur tumor imi ventris, . . . et ad digitorum 
illisionem sonitus tympani oboritur. " De re med., lib. iii, cap. 
lxx, De infiatione uteri ; Ed. H. Steph., t. i, p. 487, B. 

\ " La tumeur aqueuse ne sonne comme vent, mais comme 
eau." — Chir. de J . Tugault, Lyon, 1580, p. 143, d'apres M.. 
Pigne. 

§ ' { Si a flatibus (uteri hydrops) excitetur, imus venter per- 
cussus sonitum edit ... Si verd ab humore seroso fiat, grav- 
itas major adest in parte, et sonus veluti fluctuantis aquae. " — 
Biverii Opera med. omnia, cap. xii, p. 391, Geneve, 1737. 

|| " A tumore flatuoso distinguitur qui murmur 

acsonum edit, qui in scirrho (lienis) non reperiuntur." — Ibid., 
cap. iv, p. 333. 

7* 



78 PERCUSSION. 

and combined so as to constitute a method. 
Auenbrugger is the first who occupied him- 
self with percussion in an especial manner ; 
and he may, by just claim, be considered 
as its inventor. However, in spite of the 
treatise which he published in 1761,* his dis- 
covery passed almost unobserved, and per- 
cussion was not slow in falling back into ob- 
livion. 

To Corvisart belongs the merit of having 
caused it to revive in France, and of having 
spread the use of it abroad. However, as it 
was practised at that time, immediate percus- 
sion was not without inconvenience; its ap- 
plication was restricted and its data had not 
the desirable exactness. 

To Mr. Piorry the science owes that per- 
fecting of which it was in need. Thanks to 
a happy modification, percussion made medi- 
ate has been more frequently applicable, and 
its results have become much more exact. 
At the same time, Mr. Piorry fixed its value 
by numerous experiments upon the dead 

=* Inventiim novum ex yercussione thoracis humani, &e. Vi- 
enna, 1761. Translated into French by J. N. Corvisart, under 
the title of " Nouvelle inethodepour connaitre les maladies de la 
poitrine par la percussion de cette cavite. " Paris, 1808. (New 
method of recognizing diseases of the chest, by the percussion 
of that cavity.) 



GENERAL RULES. 79 

bocty, he traced its rules with extreme care, 
and gave it greater extension by applying it 
to a great number of cases, in which it was 
not yet employed. From that time, percus- 
sion has become more popular every day, and 
this method now constitutes, with ausculta- 
tion, the most solid basis of diagnosis. 

GENERAL RULES. 

In order that percussion may furnish sure 
and useful results, the observation of several 
general rules is necessary. The physician 
should, above all, choose a convenient posi- 
tion : in general he may place himself indis- 
criminately on the left or on the right of the 
patient; the important point is for him to be 
at ease, in order that he may conveniently 
percuss, at a right angle, and with an equal 
force, the different regions that he explores; 
he must also strike neither from too near, nor 
from too far; too great a difference in the dis- 
tance from which he strikes not being without 
effect on the difference of the sounds pro- 
duced. Further, if the results of the explo- 
ration appear doubtful, the physician can pass 
alternately from the left to the right, repeat- 
ing the examination every time in inverse 



V 

80 PERCUSSION. 

positions. It often happens that by means 
of this counter-proof, we confirm a doubtful 
estimation, or reform an erroneous first judg- 
ment. 

Percussion may be immediate, that is to 
say, practised directly upon the parts of which 
we desire to ascertain the degree of sonorous- 
ness. In this case we percuss with the ends of 
the four fingers united in a line, and stretched 
out, or rather lightly bent, so as to form an 
angle more or less right with the metacarpus, 
but always kept near each other; we can also 
percuss with the flat of the hand, or at times 
even with the end of the stethoscope, if we 
only desire rapidly to take an idea of the 
general sonorousness of the thorax, before 
proceeding to a more regular and more com- 
plete exploration. 

This mode of operation is frequently in- 
convenient : generally the sound that is drawn 
from parts thus struck is obscure, or badly 
delineated; in order to obtain it more distinct 
and pure, we must employ a certain force, 
and then percussion becomes painful to the 
patient, above all if we operate on inflamed 
parts; it is not at all practicable on the mam- 
mae ; it is difficult in fat persons, whose tho- 
racic walls have great thickness, in dropsical 



GENERAL RULES. 81 

persons, whose subcutaneous cellular tissue 
is infiltrated with serosity; it is still less prac- 
ticable upon the abdomen, which does not 
offer the elastic resistance of the thorax. It 
is not even without danger; blows direct and 
little guarded may produce a grievous con- 
cussion in the parts struck, and if they are 
too violent, may produce, for example, the 
rupture of a cyst, or of an aneurismal tu- 
mor. 

This is not all : a few smart shocks given 
to the walls of the chest will allow us to 
have a summary idea of the general sonorous- 
ness of the thorax; this manner of proceed- 
ing, perhaps suffices to prove a very manifest 
change of sound, and to make known a very 
extensive lesion, but it will allow lighter 
modifications to pass unperceived, and will 
cause us not to appreciate very limited lesions. 
But if it is necessary sometimes to content 
ourselves with this immediate and rapid per- 
cussion, in cases where the weakness of the 
patient opposes itself to a long examination, 
every time that it is possible to choose, we 
must prefer mediate percussion. 

The latter consists in interposing a body 
of a variable nature between the hand that 
strikes, and the part struck. This process 



82 PERCUSSION. 

has au incontestable superiority over the pre- 
ceding. 

The sounds that are produced are clearer 
and more distinct ; there is need of much less 
force to obtain them, and the intermediate 
body weakens the shock of the hand that 
strikes ; mediate percussion is consequently 
much less painful, it can be prolonged with 
more facility, and practised without danger on 
delicate or sensitive parts, and it becomes ap- 
plicable in cases where direct percussion could 
not be employed ; it permits us to recognize 
lesions that are not strongly marked, and are 
of small extent ; it furnishes the means of 
bounding diseased organs, and of estimating 
their forms ; consequently, of following them, 
so to speak, in the physical changes which 
their volume may undergo ; finally, it may 
also give us an idea of the different degrees 
of their density, by the greater or less resis- 
tance, that the finger feels. 

In mediate percussion, the body interposed 
may be, either the pleximeter of Mr. Piorry, 
or a plate of caoutchouc, or the finger of the 
observer. The pleximeter {r^aau>^ I strike, 
f^rpov^ a measure), is a plate of thin ivory, 
circular or oval, plane upon its two faces, 
furnished at the two opposite points of its 



GENERAL RULES. 83 

great diameter, with vertical laminse or ears, 
intended to fix it in place.* Very conveni- 
ent for the percussion of the abdomen, and 
upon corpulent chests which present a uni- 
form plane, the pleximeter offers fewer ad- 
vantages when we investigate a patient whose 
thorax is mucii attenuated; it is not easy 
to apply it exactly in intercostal, depressed 
spaces, without causing some pain, and the 
peculiar resonance of the stricken ivory 
mixing with the sounds given out by the 
interior organs, might affect the purity of 
them.f To avoid these inconveniences, it 

* For the very numerous modifications that the pleximeter 
has been made to undergo, for its graduation, for the different 
hammers destined to replace the finger which percusses, <fcc, con- 
sult the special works of Mr. Piorry, on mediate percussion, &c, 
1818 ( De la percussion mediate) ; Of the operation to be fol- 
lowed in the exploration of organs by percussion, &c, 1831 
(Du procede operatoire a suivre dans V exploration des organes 
par la. percussion) ; and the treatise of Mr. Maillot, Practical 
Treatise on Percussion, &c, 1843 (Tr a it e pratique de percus- 
sion) . 

f These are the rules drawn out by Mr. Piorry, for the use of 
the pleximeter : The instrument will be kept solidly fixed be- 
tween the thumb and the indicator of the left hand, and very 
exactly applied to the parts, so that it shall in some degree 
make one body with them-. When we desire to obtain a great 
deal of sound from an organ, the fingers which percuss ought to 
be held in the following manner : the index and the medius ought 
to be exactly adapted to each other, by bending the medius a 
little more, on account of its greater length, so that its extrem- 
ity shall not pass beyond that of the indicator. The thumb is 



84 PERCUSSION. 

has been proposed to reduce the size of the 
pleximeter, or to substitute for it a little plate 
of caoutchouc, whose application can be made 
more accurately, and without pain, but with 
which it is difficult to produce much sound. 
Digital percussion therefore seems to us prefer- 
able ; the finger, composed of hard and soft 
parts, approaches in its structure that of the 
thoracic walls, and produces less change in 
the sounds which these send forth. Pressure 
in cases where it becomes necessary, is less 
painful; thin and narrow, it is easily put be- 
tween intercostal spaces, or upon depressed 
spots ; flexible, it moulds itself to prominent 
or even to rounded parts ; organ of touch, it 
adds tactile sensation to the perceptions of 
hearing. Finally, and it is a consideration 
not to be despised, the finger is always at the 
disposal of the physician, whom the loss of 
his pleximeter might embarrass. 

It is upon the index, and much better still 
upon the medius, that percussion is generally 

then propped with force against the joint of the second and 
third phalanges of the indicator. These three fingers thus re- 
united, constitute then a very solid whole, whose percussing sur- 
face, if the medius is a little bent, has only the extent of the 
pulp of the index alone. It presents the dimension of the end 
of these two fingers united, if they are kept on the same line* — 
O71 the operation, fyc. {Du procede operatoire, fyc), p. 44. 



GENERAL RULES. 85 

made ; it is almost always placed in pronation, 
but rarely it is more convenient, on account of 
the attitude of the patient, to strike upon the 
palmary face of the finger, reversed in supina- 
tion. We generally proceed in the following 
manner : 

The whole of the left hand* is applied to the 
region whose sonorousness we wish to inves- 
tigate, and it is thus kept fixed ; then the me- 
dius is isolated from the other fingers ; well 
stretched, it adapts itself exactly to the sub- 
jacent parts, by means of a light pressure, if 
the latter are painful, or if we have to do with 
an organ superficially situated, and stronger 
if there is no pain, or if we are exploring 
deeply-seated organs. The motions of the right 
hand which strikes, ought not to be from the 
shoulder, nor even from the elbow, but ex- 
clusively from the wrist ; they are thus more 
measured, and more precise, and the shocks 
much less painful to the patient, at the same 
time that the sounds produced have more 
clearness. 



* It is rare for any one to be sufficiently ambidextrous to 
execute the same movements in an inverse manner ; it would 
be better, as we have said, to pass on the other side of the pa- 
tient, if percussion present any difficulty in that position. 

8 



86 PERCUSSION. 

If it is necessary to strike with a certain 
amount of force, on account of the thickness 
of the thoracic or abdominal walls, or of the 
depth at which the viscera are placed, and if 
the absence of pain permits these blows to be 
somewhat energetic, we percuss with the 
three fingers brought near to each other, and 
bent at a right angle. Two fingers are suffi- 
cient if less force is needed: but if the 
parts struck are the seat of acute pain, or if 
the organs that they cover are superficial, 
even light percussion with the medius alone 
will give a sufficient result. 

In general, we should accustom ourselves 
to striking gently; this manner of operating 
adds to the advantage of being less painful, 
that of preserving the internal sounds in all 
their integrity. In all cases, the percussion 
ought to be moderate at first, to accustom the 
patient to it; the practitioner will afterwards 
use increasing force, and stop at that man- 
ner which gives the best results. Superficial 
or profound percussion is also demanded by 
different situations, whether of the organs in 
relation to each other, or of lesions in one or 
another stratum of these organs.* 

* Mr. Maillot thus expresses himself on this subject, in ac- 
cordance with the precepts of Mr. Piorry : "A light percussion 



GENERAL RULES. 87 

The hand which percusses is brought down 
and raised by turns, and strikes perpendicu- 
larly several successive blows separated by 
very short intervals ; sometimes we are satis- 
fied with a short and dry shock, after which 
the finger rises immediately; at other times, 
on the contrary, we leave it some seconds in 
contact, with the aim of arresting the sonorous 
vibrations, and consequently of judging better 
of the degree of resistance and hardness of 
the subjacent organs. 

Habitually, we begin by percussing in the 
centre itself of the region corresponding to 
the diseased organ. But it is often more ad- 
vantageous to explore at first the surrounding 
parts, and thus to arrive progressively at the 
ailing viscera. In this way, the contrast be- 
tween the healthy parts and those which 
are the seat of lesions is more evident, and 
the ear seizes better the lightest shade of 
sound, which expresses immediately a physi- 
cal change, even when but little marked. 

Sometimes it is important to designate by 
lines, with nitrate of silver, or better still 

will permit us to estimate the superficial strata of the lung ; and 
rendered stronger by successive degrees, it will enable us to 
judge of the density of the lungs at different depths." (Loc. 
cit., p. 75.) 



88 PERCUSSION. 

with a soft pencil, the points where the lesion 
begins, and to define the ailing organs ; this 
exact circumscription, constantly practised by 
•Mr. Piorry, and which he has generalized 
under the name of organography* [organ- 
ographisme), allows us to follow, as if step by 
step, the increasing or decreasing progress of 
the disease, and it may consequently be the 
source of valuable indications for prognosis 
and therapeutics. 

Besides the general rules that we have just 
drawn out for the physician who percusses, 
there are still, as relates to the patient, certain 
rules that it will be well to observe. The 
region examined ought to be naked or cover- 
ed with thin clothing ; stuffs of silk and wool 
will be proscribed on account of the sounds 
produced by their friction. 

As to the position of the patient, — generally 
symmetrical, it will vary according to the 
regions that are sounded. Sometimes it will 
be necessary to modify it during the same 
examination, and, for example, if the question 
is to discover the presence of an effusion in 
the pleura, and especially in the peritoneum, 

* See 1' Atlas de Plessimetrisme, Paris, 1851 (The Atlas of 
Pleximetry) . 



PULMONARY APPARATUS. 89 

we give the trunk different inclinations in 
order to carry and unite the liquid in the 
parts declined.* 



DIVISION. 

Percussion is applied especially to the chest 
and abdomen, and exceptionally to the head, 
neck, and members. 



Sec. I. Percussion of the Chest. 

The percussion of the chest comprises the 
examination of the pulmonary apparatus, and 
that of the circulatory apparatus. 



Chapter I.— PULMONARY APPARATUS. 

| 1. Especial Rules. 

For percussion of the anterior part of the 
thorax, the patient may stand; but as the 
body wants support in this position, it is 
better for him to be seated, with the back 



* It is superfluous to add that in percussion as well as in 
auscultation, silence around the observer is necessary during 
the whole time of the examination. 



90 PERCUSSION. 

propped. In either case, the arms will be pen- 
dant at the sides of the body, the head held 
straight, the shoulders slightly kept in. Lying 
upon the back, more or less horizontally ac- 
cording to the degree of dyspnoea, is prefer- 
able. The thorax thus reposes on a resistant 
plane; the arms are placed beside the trunk; 
and throwing the shoulders a little backwards 
in order to stretch the muscles moderately, 
the effort is to give to the trunk a perfectly 
symmetrical position. For examining the 
subclavicular region, on the right or left, 
the head will be carried alternately to the 
side opposite to that which is explored. 

In order that percussion of the lateral 
portions may be possible, the patient, stand- 
ing or seated on a chair, or lying on the side 
opposite to that which is to be examined, will 
raise his arms, stayed upon his head, or sup- 
ported by an assistant. 

In endeavoring to explore the posterior 
parts of the chest, the standing posture will 
not be so good as sitting in the bed or 
on a chair; in all cases the head should be 
bent, the back arched, and the arms will 
be crossed or carried in front in such a way 
that the scapula, removed from the vertebral 
column, may be fixed to the thorax with ex- 



PHYSIOLOGICAL PHENOMENA. 91 

actness and the muscles may be moderately 
stretched; too great tension would have the 
effect of diminishing the sonorousness of the 
chest. In exceptional circumstances, the pa- 
tient is put on all fours upon his bed, so that 
we may assure ourselves whether the dulness 
is movable and whether it is owing to a liquid 
susceptible of displacement. 

One especial rule, the observation of which 
is very important, is to sound the two sides 
of the chest in comparison with each other, 
under conditions entirely identical; and, for 
this purpose, percussion should be practised, 
by turns on the right and on the left, on 
points exactly correspondent, in the same 
position, with equal force, during inspiration 
and expiration. 

\ 2. Physiological Phenomena. 

Percussion practised upon the thorax in 
its different regions, produces very valuable 
sounds; the knowledge of these varieties of 
the normal state is of great consequence in 
appreciating the different modifications ap- 
pearing in the pathological condition. 

It is difficult to characterize by words the 
natural resonance of the healthy thorax: it 



92 PERCUSSION. 

is a clear sound, sui generis (pulmonal of Mr. 
Piorry), which should be well studied in ad- 
vance, by percussion upon the dead body, or 
by preference on healthy individuals, so as to 
habituate the practitioner to recognize easily 
all its shades. It is understood that this 
sound varies according to the different degrees 
of thickness of the thoracic walls. In front, 
it is clear above the clavicle (at a height of 25 
or 30 millimeters),* and upon this bone itself; 
clear and more pure yet in the subclavicular 
region (from the clavicle to the fourth rib ex- 
clusively), it loses a little of this clearness, 
especially in fat persons, on the line of the 
mammae. On the left it is obscured in the 
precordial region,f and farther down the pul- 
monal sound is formed again, until about the 
seventh rib, a point where it gives place to 
the tympanic resonance produced by the great 
extremity of the stomach. On the right it is 
clear from the top of the thorax down to a 
level with the sixth or seventh rib; setting 
out from this limit, it begins to be replaced 
by the more and more complete dulness of 
the liver. 



* The millimeter is less than 0.04 of an English inch. — Tran. 
f See Percussion of the Heart, p. 112. 



PHYSIOLOGICAL PHENOMENA. 93 

The median portion of the anterior wall of 
the thorax, in other terms the sternal region, 
offers in its upper part a clear sound, less 
pure, however, than that of the subclavicular 
region, and which, about on a line with the 
third rib, is obscured as far as the xiphoid 
appendage. 

Laterally, in a region bounded on each side 
by the vertical line let down from the ante- 
rior and posterior edges of the arm-pit, the 
pulmonal sonorousness is very great; from 
the axillary hollow to the fifth, sixth or seventh 
rib downwards. 

Behind, the sonorousness exists from top to 
bottom, in the interscapular region; but it is 
mediocre and it ceases at the level of the 
second or third false rib. More outwards, in 
a region limited externally by a vertical line 
dropped from the posterior edge of the arm- 
pit, we find the supraspinatus portion where 
the pulmonal sound is very obscure on account 
of the thickness of the thoracic wall, and the 
infraspinatus portion where the obscurity is 
a little less. Fortunately in these points we 
may, by deep percussion, obtain the sensation 
of a normal elasticity, easy to be distinguished 
from the resistance to the finger that the true 
pathologic dulness presents. Lower down, 



94 PERCUSSION. 

in a region corresponding to the angle of the 
ribs, the pulmonal sound reappears in all its 
clearness. Some centimeters* further down 
it is replaced by a dulness, produced on the 
right by the posterior edge of the liver, and on 
the left by the spleen. This inferior limit is 
generally not so low on the right, because of 
the pressing back of the diaphragm by the 
liver; sometimes, on the left side, the pulmo- 
nal sound gives place to the tympanic reso- 
nance of the distended stomach. 

Independent of these varieties which the 
pulmonal sound presents according to the 
different points where it is sounded, there are 
still differences which depend on the age of 
individuals, and on the physical condition 
of the chest. Thus the resonance is a little 
greater in old men with lean chests; it is much 
more marked, and as it were tympanic, rel- 
atively, in very young subjects, and in them 
this excessive resonance is very well explained 
by the want of thickness of the muscular 
strata. In general also, the sonorousness is 
much more intense, when the chest is large 
and its walls thin ; it is much less when the 



# Centimeter, rather more than 39-100ths of an English inch. 
-Trans. 



PATHOLOGICAL PHENOMENA. 95 

thorax is narrow, and its walls thickened by 
the development of the muscular system or by 
the bed of fat. We must not forget that in 
rickety malformations, the resonance is usu- 
ally less, in consequence especially of the 
mechanical and slow compression that the 
substance of the lung bas undergone, and of 
the thickening of the bones of the thoracic 
cage. We have often verified these physical 
changes of the pulmonary parenchyma and 
of the bony tissue in children who sink at an 
epoch when rachitis is at its ascending period. 

\ 3. Pathological Phenomena. 

In the state of disease the sound returned 
by the thorax at the points which corre- 
spond to the lungs, may present numerous 
varieties of force and of character. It be- 
comes at times clearer and more intense ; at 
times more obtuse and dull; at times again 
it is distinguished by a peculiar tone.* 

* M. Skoda took especial note of the tone of the sounds pro- 
duced by percussion. M. Woillez, who has likewise especially 
treated the tone {tonalite) of these sounds, proposes the follow- 
ing division : Any sound of percussion whatever, says he in an 
important memoir {Etudes sur les Bruits de Permission Thora- 
ciqae. Arch. Gener. de Med., Mars et Avril, 1855. Studies on the 
Sounds of Thoracic Percussion, &c), ought to be studied as a com- 
pound which has three fundamental elements which must be ex- 



96 PERCUSSION. 

A. The increase of sonorousness is shown 
under two principal forms : in the first de- 
gree, the exaggerated sound that is obtained 
by percussion preserves the character of the 
natural resonance of the chest [clear sound) ; 
at a more elevated degree, it takes on a res- 
onance analogous to that given by the left 
hypochondrium when the stomach is dis- 
tended by gases {tympanic sound). 

a. The clear sound is itself more or less 
marked; it may be general or partial, extend 
to the whole surface of the thorax, or remain 
limited to a circumscribed region of one or 
both sides of the chest. 

As sonorousness varies much in the nor- 
mal state, it is not always easy to tell whether 
in a certain individual, it is really in excess, 
especially when the chest is everywhere very 
sonorous : in this case we must consider the 
conformation of the thorax, and pay regard to 
its size as compared with the degree of plump- 
ness of the soft parts. When the excess of sound 

amined separately. Every resonance of this kind presents, 1st, 
a normal tone, either more grave or more acute ; 2d, a normal in- 
tensity either diminished or increased ; 3d, and finally, as a com- 
plementary element, there is thoracic elasticity under the finger 
that percusses, and which is also either normal, or augmented, or 
diminished (and sometimes also perverted, for instance, by the 
hydatic shuddering, — fremissement hydatique). 



PATHOLOGICAL PHENOMENA. 97 

is partial, it is easier to prove ; however, when 
it exists on both sides at corresponding points, 
we might still doubt its reality, and we must 
recall the relative shades that have been 
pointed out for the different regions. 

Finally, when it takes place only in one- 
half of the chest, we might sometimes sup- 
pose this side, pathologically more sonorous, 
to be the one whose resonance was normal, 
and believe on the contrary, that the natu- 
ral sound of the healthy side was diminished 
by a morbid condition. "We must then ex- 
amine whether there is at the same time, 
hollowness, and which of the two sides is 
more nearly normal in shape, or dilates more 
regularly; also at times, we must auscultate 
comparatively so as to decide the question. 

A simple excess of sonorousness may, as 
we have seen above, exist independent of 
any lesion of the organs contained in the 
thoracic cavity, and be only the effect of 
leanness. Often also it is a symptom of 
lesions of the walls or of the subjacent vis- 
cera : it may be met with in the case of her- 
nia of the lung and of subcutaneous emphy- 
sema ; but much more frequently it is con- 
nected with different forms of pulmonary 
emphysema. Rarely, on the contrary, is it 

9 



98 PERCUSSION. 

owing to the existence of a cavity or of dila- 
tation of the bronchi. 

Again it is undeniably established (as Dr. 
Skoda has pointed out)* in pleurisy with 
effusion and hydrothorax, below the level of 
the liquid, f 

Finally, in certain cases of pneumonia of 
the posterior and superior part of the lung, 
an exaggerated sound is heard in front, in 
the subclavicular region. 

When the exaggeration of sound is only 
the result of leanness, it shows itself every- 
where with the degrees of relative intensity 
that we have assigned to the different regions 
of the chest in the normal state ; the inter- 
costal spaces are depressed, the clavicles are 
prominent, but the chest preserves its regular 
conformation. 

Emphysema of the thoracic walls is dis- 
covered still better than by pleximetry, by 



* Auenbrugger had already noted this fact, as may be seen 
in the following passage : "Si media pars aqua repleta fuerit, 
evocabitur resonantia major in ilia parte quam aquosus humor 
non occupaverit." Hydropis pectoris signa. 

t 41 times in 51, according to the observations of one of our- 
selves (Reckerckes Cliniques, fyc). Clinic Researches upon some 
New Symptoms furnished by Percussion and on the Tympanic 
Sound in Liquid Effusions of the Pleura ; by H. Roger. Archives 
Gener. de Med., July, 1852. 



PATHOLOGICAL PHENOMENA. 99 

tumefaction of the soft parts, and especially 
by the peculiar crepitating sound which they 
give out under the pressure of the fingers. 

Hernias of the lung, without division of 
the integuments of the chest, are rare facts ; 
however, they may be met w r ith ; and if a 
soft elastic tumor, appearing on some part of 
the thorax, gives a very clear sound on per- 
cussion, we could not be mistaken in consider- 
ing it a pulmonary hernia. 

In case of emphysema of the lung, the ex- 
cess of sound may be general, extending over 
the whole chest; but it is rarely that there is 
not predominance of sonorousness, in one 
point or another of the thorax, rare for it not 
to be more decided, for example, on the line of 
the costal cartilages, or for it not to be more 
marked in one part, or in the whole, of one 
side compared to the other. Besides, most 
frequently, the chest is modified in its form ; 
it is more bulging than in the natural state ; 
the intercostal spaces are more or less raised, 
and the clavicles very slightly prominent. 
In cases of partial emphysema, the excess 
of sonorousness habitually coincides with an 
appreciable hollowness, especially at the an- 
terior part of the thorax. Let us add that 
when emphysema is somewhat considerable, 



100 PERCUSSION. 

the precordial region is itself often very 
sonorous, because the heart is found covered 
by the anterior edge of the left lung; and the 
inferior limit of this exaggerated sound de- 
scends lower than is normal, on account of 
the depression of the diaphragm.* 

On a level with pulmonary excavations, it 
is only by exception that the sonorousness 
of the chest is augmented. For this to be the 
case, the cavities must be spacious, filled with 
air alone, and the surrounding tissue must 
have remained flexible. Now it is quite rare 
to find these conditions united; besides in 
this case itself, there is not simply exaggera- 
tion of the ordinary pulmonal sound, but the 
character of the sound obtained is different, 
it is remarkable for its clearness rather than 
for its intensity, and often it approaches the 
resonance that is produced by the percussion 
of an empty vase. 

Another distinguishing mark of this clear 
sound belonging to cavities, is that it is cir- 

* Let us remark, with Mr. Skoda, that in general emphy- 
sema of the lung, excessive and accompanied above all by a 
strong tension of the thoracic walls, the sound may not only 
not be exaggerated, but also appear less intense than in the 
normal state. The case will be the same in pneumothorax 
with excessive distension of the pleura and the walls of the 
chest. (See the experiments recorded in the memoir just cited.) 



PATHOLOGICAL PHENOMENA. 101 

cumscribed to an inconsiderable extent, and 
that it is usually met with below the clavicle. 

Excess of sonorousness is also a fact rarely 
observed in dilatation of the bronchi, this 
lesion being usually accompanied by aug- 
mentation in the density of the pulmonary 
parenchyma. 

The exaggerated sound that is met with at 
times in pleural effusion, is distinguished by 
this, that it has its seat under the clavicle, 
above the level of the liquid, and that further 
down it gives place to a dulness progressively 
more marked. Finally, when the excess of 
sonorousness is caused by subjacent pneu- 
monia, auscultation intervenes uselessly to 
determine its morbid signification. 

b. The tympanic sound* of the chest is en- 
tirely analogous to that which is given on 
percussion by the left hypochondrium, when 
the stomach is distended by gases. This 

* In order not to complicate, in a compendium, the study of 
percussion, we have preserved for the word " tympai/isme" the 
restricted sense that Laennec attached to it ; Messrs. Skoda, 
Woillez, etc., took it in a much more extended acceptation, and 
consequently met with the tympanic sound in a great number 
of diseases. (See the Treatise on Percussion of the German 
doctor, and the memoir of M. Woillez on tympanisme in 
the Chest. Die Tympanisme dans la poitrine. Arch. Gen. 
de Med., Sept. 1856.) 

9* 



102 PERCUSSION. 

resonance usually takes place only on one 
side of the thorax ; rarely also it extends to 
a whole half of the chest, and habitually it 
occupies only a more or less considerable 
space. Frequently it appears in an abrupt 
manner, at the same time with a dilatation 
of the pectoral walls on the corresponding 
side; rarely it persists in the extent at which 
it was first verified, and in general it is quickly 
circumscribed. 

This remarkable sonorousness indicates a 
gaseous effusion in the pleura. Its intensity 
is generally in proportion to the quantity of 
gas poured out, and gives the measure of the 
compression that the lung has suffered;* the 
extent in which it is perceived is in relation 
to the space occupied by the elastic fluid. 

It is rare for the tympanic sound to extend 
to a whole side, because usually pneumo- 
thorax supervenes in consumptive patients 
in whom the lung has contracted adhesions 
to the top of the chest. At the beginning 
of this pathological state, the phenomenon is 
at times perceptible even to the base of the 
thorax; and as this morbid resonance has 
much analogy with the normal tympanic 

* See the end of the note, p. 100. 



PATHOLOGICAL PHENOMENA. 103 

sound of the stomach, we might sometimes 
commit an error, and believe in pneumo- 
thorax, when in a tuberculous patient the 
stomach, distended by gases, pushes back 
the diaphragm towards the superior part of 
the chest; but auscultation will dissipate 
all doubts. Besides, the introduction of air 
into the pleura is not slow in giving cause to 
inflammation of this membrane, and to a 
liquid effusion which is made known by a 
greater or less dulness in the inferior regions. 

It is auscultation again which comes to 
the succor of the physician, in these some- 
times rather difficult cases of differential 
diagnosis, when the gaseous effusion having 
formed in the pleural cavity slowly and in 
small quantity, without simultaneous develop- 
ment of grave functional symptoms, pneumo- 
thorax would give cause to a tympanic res- 
onance but little marked, which might in- 
duce the belief that this was a case only of 
the exaggerated sonorousness of pulmonary 
emphysema. 

B. Diminution in the sonorousness of the 
chest may also present different shades; we 
habitually distinguish two varieties, namely: 
the obscure sound and the dull sound. 

a. The sound is called obscure, when there 



104 PERCUSSION. 

is still a certain amount of resonance, and in 
this case, the resistance to the finger is gener- 
ally but little marked. This obscuring of the 
sound may also be met with independent of 
any morbid condition, and may be the effect 
of considerable development of the muscles, 
or of thickness of the bed of fat. We per- 
ceive that this phenomenon is not pathological, 
by this peculiarity, namely, that it exists on 
both sides; equal at correspondent points, 
and that it presents, in different regions, 
the degrees of relative density that we have 
pointed out. 

The obscuring of the sound is frequently 
observed in morbid conditions, either of the 
thoracic walls, the pleura, or the lungs. 

The single fact of a strong tension of the 
walls of the chest, whatever be the cause 
thereof, is sufficient to produce a more or 
less obscure sound. It is the same in cedem- 
atous infiltration of the walls of the thorax, 
but this lesion is better revealed by the ready 
depression of the skin. An abscess developed 
in the walls might also produce an obscure 
sound, limited by a circumscribed tumefac- 
tion. In some patients attacked by intense 
pleurodynia, it has appeared to us that the 
pulmonal sound was diminished, and this 



PATHOLOGICAL PHENOMENA. 105 

diminution has seemed to us to take posses- 
sion especially of the incomplete ampliation 
of the diseased side. 

Much oftener obscurity of sound belongs 
to lesions more deeply seated. It often ex- 
ists in pleurisy, and is met with either at the 
beginning of this inflammation, when there 
has formed in the pleura an effusion of liquid 
as yet inconsiderable, and especially when 
the partial adhesions of the two pleurse allow r 
the liquid to mount between them under the 
form of a light layer, or later when the 
pleural leaves are hung w^ith thick false 
membranes infiltrated by serosity; or later 
yet, when the lung, long compressed, and 
enveloped by pseudo-membranes, can no 
longer return to its primitive volume, and 
the walls of the chest yield. At times also, 
the diminution of sonorousness depends on 
light hydrothorax. In all these cases, it has 
usually its seat at the base of the chest. In 
simple hydrothorax it is displaced when the 
patient is obliged to change his position; this 
displacement is, on the contrary, difficult or 
impossible in the other affections of the pleura 
that we have just mentioned. 

Obscurity of sound is found again when- 
ever the pulmonary parenchyma has lost its 



106 PERCUSSION. 

lightness and has become more dense; in 
congestion, at the beginning of pneumonia, 
in hypostatic choking (engouement), in phthisis, 
and in serous or sanguine infiltration of the 
pulmonary tissue (apoplexy or oedema) ; or yet 
again consecutively in dilatation of the bron- 
chi, or at the development of different morbid 
productions, such as cancer and melanosis. 

In all these cases, the dulness is fixed, and 
it presents no especial characteristic which 
can serve in differential diagnosis. Never- 
theless, in pulmonary hypostatic congestion, 
it is only behind and below that the sound is 
diminished; somewhat habitually the same 
is the case in pneumonia. 

In phthisis, on the contrary, it is especially 
at the top that we verify the obscurity of the 
sound, either behind or under the clavicles. 
In other affections, there is nothing especial 
in the seat of the obscure sound, and we must 
necessarily recur to other methods in order to 
establish the diagnosis. 

b. The sound is called dull when it resem- 
bles that heard in percussing the thigh (tan- 
quam percussi femoris). It may have a varia- 
ble seat and extent, may occupy sometimes a 
whole side of the chest, or be limited, on the 
contrary, to a circumscribed point. It is 



PATHOLOGICAL PHENOMENA. 107 

generally accompanied by a resistance to the 
finger, more or less noteworthy. 

Dullness depends either on a considerable 
induration of the lung, such as that which is 
produced by very numerous tubercles, or by 
pneumonia at the period of hepatization, or 
on a pressing back of its tissue by the inter- 
position of an abundant effusion of serosity, 
of blood, or of pus : more rarely is it owing 
to tumors developed in the walls of the tho- 
rax, in the pleura, or situated more pro- 
foundly, and in contact with the ribs. 

As for tumors of the walls, the dull sound 
teaches only that they are solid or liquid : but 
palpation and the other methods of examina- 
tion are indispensable, in order to determine 
the nature of the dulness. As for tumors 
more deeply seated, they usually produce a 
circumscribed dulness, whose seat is by no 
means fixed. This dulness announces that in 
the subjacent point there exists a dense and 
compact body; but this dull sound alone 
cannot inform us precisely whether there is 
aneurism or a cancerous tumor, and the aid 
of other means of exploration becomes neces- 
sary. ^ 

Is it possible to distinguish whether the 
dull sound should be attributed to a considera- 



108 PERCUSSION. 

ble effusion, or to an induration of the pul- 
monary parenchyma? In general, in pleu- 
ral effusion, the dulness is more complete; 
it usually has its maximum at the base of the 
chest, and diminishes by little and little, as 
in percussing we ascend towards the top of 
the thorax. It stops at a variable distance 
from the top, at a higher level behind than 
in front, or, indeed, if it goes as far as the 
clavicle, this extent itself, approximating to 
its intensity, becomes an indication of effu- 
sion. Another symptom of these considera- 
ble collections of liquid, is the pressing t)ack 
of the heart, which is forced back as far as be- 
hind the sternum, and even as far as under 
the right false ribs, if the effusion takes place 
in the left pleura. This is not all : in a case of 
partial effusion, it is sometimes possible, by 
varying the position of the patient, to produce 
displacement of the dulness. This mobility 
of the phenomenon will be, besides, much less 
apparent in pleurisy than in hydrothorax, an 
affection in which no false membrane nor ad- 
herence prevents the liquid from obeying the 
laws of gravity. 

If, on the contrary, there is induration of 
the lung, the dulness will be fixed and inva- 
riable, whatever be the attitude of the patient. 



PATHOLOGICAL PHENOMENA. 109 

Iu general, also, it is less intense, and it is 
rarely seated in a whole side of the chest ; it 
is oftener limited to a variable extent of the 
thorax, more decided in one point, and di- 
minishing, if we set out from this centre, in 
such a way as to be confounded by degrees 
upon its boundaries with the natural reso- 
nance. If the dulness is owing to pulmonary 
hepatization, it will have its place on one side 
especially, along the posterior and inferior 
edge, more rarely at the top, and almost 
never in front alone. 

In cases of tubercles, on the contrary, the 
dull sound will have its seat at the top, 
either behind or in front, often on both sides 
at the same time, and will extend, while 
diminishing in intensity, even towards the 
middle part, but scarcely ever so far as the 
base, unless there be complication of chronic 
pleurisy. 

However, in order to carry on the diagno- 
sis with some certainty, we must not rely 
alone on the data of percussion; we must 
bring together with care the results furnished 
by other methods of examination, and not de- 
cide until after having compared them with 
the functional symptoms, and with indications 
drawn from the progress of the disease. 

10 



110 PERCUSSION. 

C. We have now examined the modifica- 
tions in degree of the pulmonal sound, either 
greater or less, but there is another shade of 
sonorousness, of which we must make men- 
tion. 

We have seen above, that there is fre- 
quently met with at the summit of the chest, 
in front, a clear and hollow sound, circum- 
scribed to an inconsiderable space, and de- 
pendent on the presence of a superficial 
cavity, which contains only air. Rarely this 
clear sound is analogous to the truly tympanic 
sound of pneumothorax ; it will not resem- 
ble it unless the excavations are very spa- 
cious. Much oftener it takes an especial 
metallic tone, in cases where the cavity con- 
tains, at the same time, air and liquid sub- 
stances (hydro-serian sound). This sound can 
be observed again in pneumo-hydrothorax, at 
the point of contact between the gas and the 
liquid, and even exceptionally in pleurisy or 
hydrothorax, either above the level of the 
effusion, or, according to Mr. Piorry, in the 
neighborhood of an organ dilated by gases, 
such as the stomach or the intestines. 

Finally, sometimes we produce by percus- 
sion of the subclavicular region, a clear 
sound, accompanied by a peculiar little clap- 



CIRCULATORY APPARATUS. Ill 

ping, whence there results a noise like that 
which a cracked vase gives out when struck 
by the finger, and which has taken thence the 
name of the sound of a cracked vessel (bruit 
de pot fele). 

In order to display this last phenomenon 
in a distinct manner, we must generally strike 
only a single blow, recommending to the pa- 
tient to hold his mouth open. It announces, in 
the immense majority of cases, a pulmonary 
cavity generally tuberculous; but it is not 
invariably produced, and in order to obtain 
it, the excavation must have a certain extent; 
it must be somewhat superficially situated; 
its walls must be thin and supple, and especi- 
ally it must contain air and liquid. 



Chapter II.— CIKCULATORY APPAEATUS. 

Percussion of the Heart and the Great Vessels. 

g 1. Especial Kules. 

The greater part of the rules that we have 
drawn out with regard to percussion, applied 
to the pulmonary apparatus, find their place 
here also. Generally, a moderate percussion 
is sufficient to discover the portion of the heart 
which is in immediate contact with the pec- 



112 PERCUSSIOX. 

toral walls; but to have an idea of the real 
volume of this viscera, to discover the part 
hidden under the anterior edge of the left 
lung, percussion must be more profound, and 
practised with more force. 

The practitioner should always percuss ver- 
tically at first, then horizontally ; often it is 
useful to determine more exactly still the 
limits of the dulness in every direction; and 
in order to have more exact results, and to be 
able to judge of the changes which may take 
place from one day to another, it is well to 
mark them out with lines by means of the 
dermographic pencil. 

\ 2. Physiological Phenomena. 

The prsecordial region supplies, in the nor- 
mal state, an obscure sound whose degree 
and extent are never absolutely invariable. 

In fact, the heart is more or less covered 
by the anterior edge of the left lung, and 
these differences necessarily produce great 
variations in pleximetric results. However, 
according to the generally received estimates, 
the normal dulness of the precordial region 
is from five to six centimeters in every direc- 
tion. It begins above, about the fourth rib, 



PHYSIOLOGICAL PHENOMENA. 113 

and extends below as far as the sixth; it has 
its maximum in the centre of this region, 
and laterally it is confounded by degrees 
with the pulmoual sound. Below and on the 
left, it is replaced by the stomachal sound; 
below and towards the right side, it is often 
confounded with the dulness of the left edge 
of the liver, which borders upon the heart, 
or reaches as far as that organ, in such a way 
that it is quite difficult to trace exactly the 
limit which separates these two viscera. 

The dulness which is found at the precor- 
dial region by a moderate percussion, does 
not give (as we have said) the real measure 
of the dimensions of the heart; it bears rela- 
tion only to the extent in which the organ 
immediately touches the walls of the chest. 
A stronger and more profound percussion is 
needed to recognize the parts hidden by the 
lung, and the obscure sound then extends be- 
yond the aforesaid limits, to an extent which 
varies according to the differences of volume 
of the heart, in various ages and various indi- 
viduals. 

As for the great vessels taking their rise 
in the heart, their presence behind the ster- 
num slightly modifies the sonorousness of the 
chest; and according to the researches of Mr. 
10* 



114 PERCUSSION. 

Piorry,* it should produce an obscure sound, 
quite distinct from the pulmonary resonance. 
This light dulness should exist over a breadth 
of sixteen to twenty lines, near the base of 
the heart, where the aorta and pulmonary 
artery are joined to each other, but will not 
be more than ten to twelve lines in places 
where the aorta ascends alone behind the 
sternal wall. 



g 3. Pathological Phenomena. 

The dull sound which the precordial region 
gives forth in the normal condition, may, in 
a morbid state, diminish in intensity and in 
extent, and even give place to an excess of 
sonorousness. 

Exaggerated resonance is almost always 
due to emphysema of the internal edge of the 
lung, which covers the anterior face of the 
heart ; more rarely it coincides with atrophy 
of this organ, which allows the two lungs to 
approach each other by their internal edge. 
Much more rarely yet, the excess of sonorous- 
ness depends directly upon a lesion of the 

* On the Pleximetric Examination of the Aorta, &c. Arch. 
Gee. de Med, December, 1840. (De Vexamen pfossimetrique 
de Vaorte.) 



PATHOLOGICAL PHENOMENA. 115 

central organ of circulation, that is, by an ac- 
cumulation of gas in the pericardial cavity ; 
in fact, pneumopericardium is an entirely 
exceptional affection. If the sound assumed 
a hydroaeric tone (hydroaerique), it might an- 
nounce a collection of liquid and of gas in the 
cavity of the serous membrane. 

The changes in sonorousness which are 
under the influence of pathological conditions 
of the central circulatory apparatus, consist 
much oftener in an increase of the natural 
obscurity of the precordial region; the latter 
then changes into a dull sound, both more 
marked and more extensive, with proportion- 
ate increase of resistance to the finger. These 
phenomena depend either on the presence of 
voluminous clots in the cavities of the heart, 
or rather on eccentric hypertrophy of this 
organ, or on a liquid effusion in the peri- 
cardium (hydropericardium, pericarditis), or 
again on the combination of several of these 
morbid conditions. 

Some peculiar characteristics of the dulness 
will serve to establish the differential diag- 
nosis. 

Thus, in hydropericardium, if the effusion 
is very abundant, the dull sound will occupy 
a triangular space, whose base will touch the 



116 PERCUSSION. 

diaphragm. Further, the superior level or 
the lateral limits of the dull sound may some- 
times vary with the attitude of the patient; 
and, for example, when he remains seated, 
the transverse diameter will exceed the ver- 
tical. Let us add that, in hydropericar- 
dium, dulness often supervenes, and extends 
with rapidity. The case is not the same in 
hypertrophy; the latter develops slowly; the 
space occupied by the dull sound is usually 
in proportion to the increase in volume of 
the heart, and may give the approximate 
measure of its form, and of its dimensions; 
we must, however, remember that the com- 
plication of pulmonary emphysema, so fre- 
quent in organic diseases of the circulatoiy 
apparatus, is an obstacle to the exactness of 
this measurement. 

According to Corvisart, and to Mr. Piorry 
and Messrs. Cammann and Clark (see p. 157), 
the data famished by percussion would allow 
diagnosis to be carried still further, and to 
distinguish dilatation of the heart with thin- 
ning from dilatation with hypertrophy of 
the walls, as w T ell as to recognize isolated 
changes in one cavity or another, &c. 

In certain cases, a dulness more or less 
marked, more or less extensive, shows itself 



PERCUSSION OF THE ABDOMEN. 117 

upon the track of the aorta ; considered alone, 
this symptom would be of no great value, 
because every kind of tumor situated behind 
the thoracic wall, in the direction of that ves- 
sel, would be marked by the same diminution 
of natural sonorousness. However, an abnor- 
mal dulness in the region of the sternum may 
announce, sooner than any other symptom, 
the existence of aneurism of the ascending 
aorta, and the examination of other concomi- 
tant phenomena will complete this first se- 
meiotic datum. 



Sec. II. Percussion of the Abdomen. 

I 1. Especial Bules. 

For the percussion of the abdomen, which 
is principally practised on the anterior wall, 
the patient will be placed upon his back, in 
a symmetrical position, the arms along the 
body; the thighs, a little raised, will be slightly 
bent, so that it may be easy to depress the 
abdominal wall, and thus to come nearer to 
the profound organs. This moderate relaxa- 
tion is as much more necessary, as too great 
a tension of the muscles has the effect of 
hardening them, and of rendering more ob- 



118 PERCUSSION. 

scure the sound furnished by the subjacent 
viscera. 

In order to explore the lateral parts, the pa- 
tient will lie upon his side, on the one oppo- 
site to that which is to be explored; and, 
for the examinations of the regions cf the 
back he will lie upon his belly, or will keep his 
seat, the body bent forwards. We shall often 
make him lean, either to the right, or to the 
left, in order to see whether these changes of 
attitude produce displacements in the dulness; 
and we are rarely obliged, with the same aim, 
to have the patient put upon all fours. 

As for the physician, he will remain stand- 
ing, on either side, and he will percuss, in 
different directions, according to the organ 
which is to be explored. If in the examina- 
tion of the different regions of the abdomen, 
digital percussion has the advantage of being 
immediately allied to palpation, the plex- 
imeter has, in compensation, that of being 
able to be carried with the greatest facilitv 
around the abdominal viscera, in order to 
measure their circumference ; and if, in 
percussing the chest, the finger generally 
suffices, here the plate should sometimes be 
employed in preference. It will be especially 
useful, if the belly is very sensitive, because 



PHYSIOLOGICAL PHENOMENA. 119 

the pressure of the pleximeter, acting with 
uniformity upon a more extended surface, 
will be much less painful. 

It is over the abdomen especially that per- 
cussion ought to be at times very superficial, 
and at times profound ; and the plate will be 
of use in depressing the abdominal wall, in 
order to study the sound of the parts deeply 
situated in the belly. 

m 

\ 2. Physiological Phenomena. 

The abdomen in its various regions, pre- 
sents, from the point of view of its normal 
sonorousness, very great differences, which 
are in connection with the structure and the 
very different density of the organs contained 
in its cavity. In order to study it, we may 
divide it into three horizontal zones, which 
include from above downwards: 1st, the epi- 
gastric and right and left hypochondriac 
regions; 2d, the umbilical region and the 
flanks, which correspond behind to the loins; 
3d, the right and left hypogastric and iliac re- 
gions. 

At the epigastrium, the sound is a little dull 
at the upper and right portion, over a variable 
extent, because of the presence of the left 



120 PERCUSSION. 

lobe of the liver, which encroaches ixi ore or 
less upon the epigastric hollow. From the 
rest of this region, which is in relation with 
the stomach, we obtain a clear sound (sto- 
machal) which becomes hydropneumatic (hu- 
morique) if the stomach contains gases and 
liquids, and more or less obscure if it is filled 
with alimentary substances. The right hypo- 
chondrium gives out a dull sound (hepatic) 
which extends from below upwards, from the 
sixth or seventh rib (five inches below the 
clavicle, according to Mr. Piorry) as far as the 
edge of the false ribs, beyond which we dis- 
cover the intestinal sonorousness. This dul- 
lness, a little less marked above, in conse- 
quence of the habitual interposition of a 
slight lamina of the lung, is at its maximum 
at the middle; farther down, the liver dimin- 
ishing in thickness, we find again, by means 
of profound percussion, the clear sound of 
the intestines obscured by the hepatic dul- 
ness. Horizontally, the dull sound is pro- 
longed on the right side backwards, and on 
the left it stops at from three to five cen- 
timeters outside of the median line, where 
it is replaced by the stomachal resonance. 
These limits, in every direction, give the 
exact measure of the length and breadth of 



PHYSIOLOGICAL PHENOMENA. 121 

the liver ; it is even possible, by a strong per- 
cussion, to judge approximately of its thick- 
ness, and consequently it becomes quite easy 
to estimate its volume. 

On the left hypochondrium, which corre- 
sponds to the large extremity of the stomach, 
there is obtained in front a clear stomachal 
sound, more marked than at the epigastrium: 
laterally and farther back, the sound becomes 
dull, because of the presence of the spleen at 
this point. The line of separation between 
the clear sound and the dull sound marks the 
internal limit of this body, whose lower limit 
is pointed out by the line where the resistance 
to the finger gives place to a certain elasticity, 
and the splenic dulness to the intestinal sono- 
rousness, at least whenever the kidney is not 
contiguous to the spleen. 

The umbilical region furnishes a sound more 
or less clear, owing to the presence of a por- 
tion of the arc of the colon in its upper part, 
and to the small intestine in the rest of its 
extent (intestinal sound). Laterally, towards 
the flanks, the sound preserves a little of its 
clearness, because of the ascending or descend- 
ing portion of the colon; but more outwardly, 
and in the whole region of the loins, it gives 
place to a dull sound on the level of the kid- 

11 



122 PERCUSSION. 

neys, which are covered by a thick muscular 
layer. 

At the hypogastrium, the presence of the 
lowest circumvolutions of the small intestine 
gives cause to a clear sound if the bladder 
and the uterus are empty. On the contrary, 
we obtain, below an invariable dulness, cir- 
cumscribed by a line curved with the con- 
vexity upwards, with hydropneumatic sound 
(bruit humorique) upon the boundary, if it is 
the bladder that is distended, and immedi- 
ately replaced by the clear sound if it is the 
uterus that is developed by the product of 
conception. Finally, in the iliac regions a 
clear sound is perceived when the ccecum or 
the iliac portions of the colon are distended 
by gases, hydropneumatic if they contain 
gases and liquids, and dull (stercoral) if they 
are filled with faeces. 

\ 3. Pathological Phenomena. 

The sounds given out by the different parts 
of the abdomen, present, in the pathological 
state, very numerous phenomena. They may 
be changed in their intensity and in their 
character, be modified in their seat and their 
limits, that is to say, increase or diminish in 



PATHOLOGICAL PHENOMENA. 123 

extent, and suffer displacements in different 
ways. Finally, there are manifested at times 
in different points of the abdomen, anomalous 
sounds which are not habitually found there, 
or even of which no trace exists in the healthy 
condition. Let us study in succession the 
changes in sonorousness of each of the viscera 
of the abdomen in particular, and those which 
may be manifested in different regions of this 
cavity. 

Liver and gall bladder. — The hepatic sound, 
without changing its character or extent, may 
be displaced like the liver itself; generally 
these displacements do not take place except 
in the vertical direction : the dulness may 
rise higher than in the natural state, so that 
its superior limits attain the fourth or even 
the third rib : this is observed in cases of 
pressing back of the liver from below up- 
wards, in consequence of an abundant peri- 
toneal effusion, or even in cases of very con- 
siderable tympanites. It may also be de- 
pressed more or less below the inferior edge 
of the false ribs by abundant collections of 
liquids or gases in the right pleura. 

In other circumstances, the hepatic sound 
occupies a more considerable space : its supe- 
rior limit rises on the side of the chest ; at 



124 PERCUSSION. 

the same time the inferior limit is depressed 
many centimeters below the edge of the ribs, 
and sometimes descends as far as the iliac crest 
and fossa; often again the dulness extends 
equally on the left, occupies the entire epi- 
gastrium, and even advances into the hypo- 
chondrium. "We cannot then mistake an 
augmentation of the liver, the dimensions of 
which we can measure by that of the dis- 
covered dulness, and appreciate the form by 
the relative increase of the dulness in the 
vertical or horizontal direction. 

But this augmentation in volume of the 
liver depends on very different lesions : it is 
due, either to cancerous masses developed in 
its thickness, to the presence of one or more 
hydatic cysts, or to a fatty condition, or 
finally to a recent sanguine congestion, or 
to chronic hypertrophy without any other 
change in texture. 

In order to fix the differential diagnosis, 
palpation will often lend useful aid to the 
pleximeter. In cases of cancer, or hydatic 
cysts, the parts of the liver which are accessi- 
ble to the touch present little projections 
more or less prominent; its inferior edge is 
also often thickened and unequal. On the 
contrary, when there is simple hypertrophy, 



PATHOLOGICAL PHENOMENA. 125 

or the fatty state, the liver habitually pre- 
serves its form, the part which goes beyond 
the false ribs is smooth, and the inferior edge 
remains thin and sharp. But in hypertrophy 
the liver is generally heavier and more dense, 
whilst in the fat state, it is usually lighter; 
and in the first case, it gives to the finger 
which percusses a greater resistance than in 
the second. We must remember besides 
that the fat state is principally met with in 
tuberculous phthisis. As for the distinction 
between cancer and acephalocystic cysts, the 
cancerous nature of the tumors will be recog- 
nized by their number, and by their central 
depression; we should sooner believe in 
acephalocysts, if there was only a single tu- 
mor more prominent and rounded, and there 
will, on diagnosis, be no further doubt, if we 
discover on percussion a peculiar shuddering 
(fremissement), of which we shall speak fur- 
ther on. 

At other times the hepatic sound occupies 
only a contracted space; its dimensions are 
diminished in all directions, and the limits 
which circumscribe it are found drawn to- 
gether from every direction. From these 
characteristics we must infer a diminution in 
volume, such as is so often observed in ad- 
11* 



126 PERCUSSIOX. 

vanced cirrhosis, and much more rarely in 
simple atrophy without any other change in 
texture. These data of percussion are, in such 
cases, so much more precious, as, because 
of ascites, a complication so frequent in the 
before-mentioned lesions, the liver, pressed 
from below upwards, and entirely hidden 
under the false ribs, has become quite in- 
accessible to the touch. 

The gall bladder, which normally escapes 
palpation and pleximetry, may be discovered 
in certain cases of considerable distension by 
an accumulation of bile or of mucous liquid, 
or even by manifold biliary concretions. In 
percussing along the inferior edge of the 
liver transversely, we discover at times, in- 
stead of the clear sound of the intestines 
which succeeds the hepatic dulness, a more 
obscure sound ; and if this peculiar dulness 
is seated at that point of the abdomen which 
corresponds anatomically to the reservoir of 
the bile, and if it shows itself of an ovoid form, 
it is more than probable that it is produced 
by distension of the gall bladder. 

Spleen. The preceding considerations are 
equally applicable to the spleen. 

This viscus may be depressed below its 
normal position, by a liquid or gaseous efiu- 



PATHOLOGICAL PHENOMENA. 127 

sion of the left pleura, or pressed from below 
upwards by considerable ascites or tympani- 
tes. In the first case, palpation is sufficient 
sometimes to recognize the position and size 
of the spleen; but in the second percussion 
can alone furnish certain data, and the 
changes of place of which we have just been 
speaking, are revealed by analogous displace- 
ments in the splenic dulness, whilst in the 
habitual place of the organ, w r e find an unac- 
customed sonorousness. 

The dulness of the region of the spleen is 
also susceptible of variations : usually three 
and a half inches in vertical extent, and 
three inches in breadth (according to the re- 
searches of Mr. Piorry), it may diminish or 
increase in a manner more or less note- 
worthy. 

Diminution of extent proceeds most fre- 
quently from distension of the stomach, or 
of the intestines by gases, and then some- 
times almost the whole splenic region may 
produce a clear sound. At other times this 
diminution is owing to the smaller volume 
of the spleen ; and if we discover this dimi- 
nution, without there being either tension of 
the epigastrium and abdomen or exaggerated 
tympanic sonorousness, we may attribute it 



128 PERCUSSION. 

to atrophy of the viscus, such as is frequently 
met with in patients who yield, in a state of 
extreme emaciation, to organic diseases of 
long duration. 

But the augmentation in volume of the 
spleen is a fact which has more importance. 
When this increase is considerable, the vis- 
cus usually passes beyond the inferior edge 
of the false ribs, and in estimating by palpa- 
tion the volume of this portion of the spleen, 
we obtain an approximate idea of its total 
dimensions; but percussion alone can give 
us an exact idea of the part hidden by the 
ribs, and thus concur in revealing its real 
volume. This is not all : although hypertro- 
phied, the organ may be pressed back, as 
well as the diaphragm, by gaseous distension 
of the belly, and in this case, the pleximeter 
is indispensable in order to determine its 
dimensions. The measure of the height is 
the easiest, and in general, in hypertrophy 
without a lesion, called organic, the increase 
in breadth and in thickness corresponds to 
that which takes place in the vertical direc- 
tion. Now the vertical dulness may rise to 
five, six, and eight inches, and indicate anal- 
ogous dimensions in the volume of the 
spleen. This increase is common after in- 



PATHOLOGICAL PHENOMENA. 129 

termittent fevers of long duration ; in some 
exceptional cases, it may be still more con- 
siderable, since the viscus has been known 
to measure as much as twelve and fifteen 
inches vertically, while it weighed eight, ten, 
or fifteen pounds, and even more. 

The increase in extent of the splenic dul- 
ness, so frequently connected with hypertro- 
phy of the spleen, may also be met with in 
other changes, such as cancers, hydatic cysts, 
&c. But these latter are much more uncom- 
mon, and besides the conformation of the 
viscus, has then undergone changes, more or 
less remarkable. 

Let us add, in conclusion, that it is not 
always easy to decide whether a dull sound, 
perceived in the splenic region, is really con- 
nected with the spleen ; and that it may be 
difficult to determine its superior limit in 
cases of hepatization of the base of the left 
lung, or of pleuritic effusion of the same side, 
as well as to specify, in ascites, its inferior 
limits; percussion carried on with different 
degrees of force w T hile changing the attitude 
of the patient, will usually avail to triumph 
over these difficulties. 

Stomach. — The clear sound produced by the 
stomach varies, even in a healthy individual. 



130 PERCUSSION. 

in extent and in intensity, according as we 
explore the organ at a greater or less time 
after a meal, in a state of emptiness or of ful- 
ness of the ventricle. However, in general, 
this sound is moderately tympanic ; it occu- 
pies the left part of the epigastrium as well 
as the corresponding hypochondrium, and it 
extends a little towards the lower regions of 
the abdomen. 

In consequence of different pathological 
conditions, the stomachal sound may become 
much more intense, assume a very decided tym- 
panic character, and, extending farther, rise 
up in the hypochondrium as far as the fifth rib, 
fill the whole epigastrium, and descend below 
the navel. By these characteristics, we recog- 
nize an enlargement of the stomach distended 
by gases, as is frequently observed in cases 
of contraction of the pylorus {hydrogaster). 
Often, also, the sound assumes a hydropneu- 
matic tone, which announces the simultaneous 
presence of a great quantity of gas, and of 
liquid matter accumulated in the cavity of 
the ventricle. 

Finally, in certain cases of dilatation of the 
stomach, by a considerable mass of changed 
chymous matter and a smaller quantity of 
gas, there is obtained by percussion, a pecu- 



PATHOLOGICAL PHENOMENA. 181 

liar sound of plashing (clapotement), produced 
at the moment when the anterior wall of the 
ventricle raised up by the gas, is hastily ap- 
plied to the liquid bed. One of us has twice 
verified this morbid sound, in patients af- 
fected with scirrhous contraction of the pylo- 
rus. 

At other times, on the contrary, the stom- 
achal sound is much less decided than in the 
natural state, and circumscribed in narrower 
limits, where, for example, the stomach is 
shortened as a result of chronic inflamma- 
tions, and, above all, by poisoning from 
acids. 

At times, also, it is a dull sound which is 
found over a certain extent, and principally 
at the epigastrium and the pyloric region. 
This dulness of the epigastrium often de- 
pends on the presence of the left lobe of the 
liver, either hypertrophied or naturally length- 
ened in the transverse direction ; but it may 
also be caused either by cancerous degeneracy 
of the walls of the stomach, or by an accumu- 
lation of blood in its cavity. 

In the first case, the dulness is permanent, 
and by strong and deep percussion we may 
find the characteristic sound of the stomach 
under the layer, either more or less thick, of 



132 PERCUSSION. 

the liver which covers it. When the dullness 
depends on a carcinomatous degeneracy, it is 
usually limited to the pyloric region, where 
we discover by the touch a movable tumor, 
whilst the tympanic sound reappears in the 
left hypochondrium. An accumulation of 
blood will be recognized, on the contrary, by 
a dulness supervening in an accidental man- 
ner in the course of a chronic affection of the 
stomach, and during the simultaneous devel- 
opment of the usual symptoms of hemor- 
rhage. 

Finally, the displaced stomachal sound may 
be found again nearer or farther from the seat 
that it occupies in the normal state ; thus we 
have seen the stomach compromised in her- 
nial tumors of the linea alba, and even of the 
inguinal ring. Percussion, in drawing from 
these tumors a clear sound, would reveal the 
presence of a portion of the digestive tube ; 
and if, after having made the patient swallow 
a certain quantity of liquid, this sonorousness 
should be abruptly changed into dulness, it 
would become incontestable that the stomach 
itself forms a part of the hernia. 

Intestines. — The sound given by the abdo- 
men may become more dull in all the points 
which correspond to the intestines, or only 



PATHOLOGICAL PHENOMENA. 133 

over a region, limited as regards these vis- 
cera. 

Dulness extended to the whole intestinal 
region often coincides with giving way and 
retraction of the intestine, and then announ- 
ces a state of vacuity of this conduit and of 
contraction of its walls, as we observe in cer- 
tain cancers of the stomach with repeated 
vomiting. 

Dulness, limited to one portion of the in^- 
testine, may be owing to very different patho- 
logical conditions. If its appearance, in any 
point whatever, of the abdomen, coincided 
with the general symptoms of hsemorrhagia, 
it might make us admit the accumulation of 
the sanguineous fluid, and even cause us to 
suspect the beginning of enterorrhagia. If, 
verified in the right iliac fossa, it occupied a 
certain extent, and if there was at the same 
time ernpdtement* and tumefaction of this 
region, it would be a sign of intestinal ob- 
struction with accumulation of alvine matter, 
and of alimentary residuum. 

In the left iliac fossa, it announces very 



* Ernpdtement. A non-inflammatory engorgement, which re- 
tains, more or less, the impression of the finger. — Dic?igliso?i , s 
Med. Diet. 

12 



134 PERCUSSION. 

often, the presence of feces amassed towards 
the end of the great intestine, in consequence 
of prolonged constipation. 

The dulness may be owing again to car- 
cinomatous degeneracy of the walls of the in- 
testine, or indeed to an intestinal invagination. 
We should easily suspect the existence of one 
of these two lesions, if the dulness coincided 
with a tumor placed on the passage of the 
ileum. 

But cancerous tumors of the small intes- 
tine are very rare ; the degeneracy most fre- 
quently occupies the colon, and the cancer 
might then be confounded with accumulation 
of feces. Its most frequent seat is the left 
iliac portion ; and as this is also the point 
where the fecal matters are most frequently 
collected, there are often in these two mor- 
bid conditions, a tumor perceptible to the 
touch, and hence possibility of an error in 
diagnosis ; this accumulation of fecal matter 
might even be taken for an entirely different 
tumor. But if liquids be then injected into 
the colon, and percussion be practised again 
after the injection has operated, if thereupon 
the dulness disappears, we perceive that there 
was a fecal tumor, and if, on the contrary^ it 
remains, we should have to believe in the exis- 



PATHOLOGICAL PHENOMENA. 135 

tence of a tumor formed by the degeneration 
of the walls of the intestine, or joined to its 
surface. 

Often it will be useful to associate these in- 
jections with pleximetry, not only in order to 
determine the presence and position of the 
great intestine, but in order to diagnosticate 
many of its diseases ; they may serve in effect, 
according to Mr. Piorry, to specify further 
the existence and the seat of a contraction of 
the colon which will neither be accessible to 
the finger nor to probes introduced into the 
rectum. If, for example, we give an abun- 
dant injection, the liquid cannot pass the line 
of the contraction ; and if afterwards percus- 
sion produces below a certain point, a dull 
sound, and above this point a clear sound, 
there is reason to admit that the contraction 
is seated at that limit where sonorousness 
gives place to dulness. 

The intestinal sound sometimes becomes 
more intense, and entirely tympanic. This 
modification is rarely limited to one part of 
the abdomen, but usually occupies a great 
extent of it. It announces the presence of a 
considerable quantity of gas in the belly : (an 
excessive quantity, with extreme distension 



136 PERCUSSION. 

of the abdomen, would cause, on the con- 
trary, a less degree of sonorousness). 

In the immense majority of cases, the elas- 
tic fluids are inclosed in the intestine, and 
constitute intestinal pneumatosis; it is entirely 
by exception that they are contained in the 
serous cavity, and form peritoneal pneuma- 
tosis. In both cases the tympanic sound is 
generalized; for the intestines swelled by the 
gases tend to fill the cavity of the abdomen, 
and the gaseous effusion in the peritoneum 
produces a general distension, by means of 
morbid adherences. However, in meteorism, 
it is rare for the tympanic sound to have the 
same intensity at all points ; frequently it is 
more marked at the level of the colon, and 
often also the intestinal convolutions manifest 
themselves through the abdominal walls. In 
true tympanites, on the contrary, the intes- 
tines being pressed backwards, the sonorous- 
ness will be more uniform. Another charac- 
teristic will serve to distinguish the two 
species of pneumatosis : in intestinal meteor- 
ismus, the liver is pushed back towards the 
thoracic cavity, but it remains in contact with 
the walls of the hypochondrium, where its 
presence is revealed by the dulness which is 
proper to it ; whilst in peritoneal tympanites, 



PATHOLOGICAL PHENOMENA. 137 

it will be pressed at the same time upwards 
and backwards, and the exaggerated so- 
norousness will extend even to the hepatic 
region. 

If the tympanic sonorousness of the intes- 
tines assumes the hydropneumatic (humor- 
ique) character, it is an indication of the sim- 
ultaneous presence of gas and of liquids. 
Sometimes these fluids are inclosed in two 
contiguous cavities, and the hydropneumatic 
sound is then obtained only on the limits 
which separate the dull sound of the one from 
the clear sound of the other; it is permanent 
in the same region, if the liquid is imprisoned 
in one of the viscera, as when the bladder is 
distended by urine, and in contact with the 
intestines swelled by gases ; it is, on the con- 
trary, subject to displacements if the liquid 
itself can be displaced, as we observe in as- 
cites, where the effusion obeys the laws of 
gravity. 

Sometimes the liquids and gases are in- 
closed in the same cavity, and usually it is the 
intestine, as we verify in the right iliac region 
in the greater number of typhoid fevers ; in 
the latter case also, a quick pressure exerted 
on the corresponding point, causes to be heard 

12* 



138 PERCUSSION. 

and felt a gurgling, which is not obtained 
when the two fluids occupy different cavities. 

Finally, the intestinal sound, as well as the 
gastric sound, may be found again at a point 
more or less removed from the seat which is 
proper to it. It is especially in cases of her- 
nia of the navel, or of the inguinal region, 
that we discover these displacements; and 
percussion, by manifesting the sonorousness 
of these tumors, proves that they are formed 
by a portion of the digestive tube. When 
the hernia is not strangulated, we may some- 
times assure ourselves, by means of an injec- 
tion through the anus, what portion of the 
intestine it is which is displaced. In fact, 
if the clear sound continues, this is a symp- 
tom that the small intestine is contained in 
the hernial sac; if the sonorousness is trans- 
formed into dulness, this is a proof that there 
is displacement of the great intestine. 

Kidney. — The kidney is so deeply seated 
behind the anterior abdominal wall, it is 
placed behind and laterally under so thick a 
layer of muscle, that it is very difficult to de- 
termine by percussion its exact seat and its 
precise dimensions. Thus pleximetry can 
scarcely be of use, except to give light to the 
diagnosis of some of its diseases, such as im- 



PATHOLOGICAL PHENOMENA. 139 

portant hypertrophies, tuberculous or cancer- 
ous degeneration, numerous cysts, hydrone- 
phrosis, or other changes with remarkable in- 
crease in volume of the organ : in these cases, 
we find a greater and more extended dulness 
in the flank and the loins of the corresponding 
side. We have observed one case of this 
kind, in which the dulness rose as far as the 
sixth rib, and descended as far as the iliac 
crest, and the kidney was found degenerated 
into an encephaloid mass of thirty-five to 
forty centimeters in length. 

Percussion might also cause us to suspect 
either absence or atrophy of one kidney, or 
displacements of this viscus, if the region in 
which it is usually found presented less dul- 
ness, and less resistance to the finger. We 
should conclude that the first of these changes 
existed, if we could not discover any unusual 
tumor in the abdomen, and the second, if we 
verified the existence of a tumor, having 
nearly the form and volume of the kidney, 
either in some point of the abdominal cavity, 
or especially near the sacro-vertebral angle, 
where we have several times found the organ 
of urinary secretion. 

Bladder. — Situated in the bottom of the 
small basin, the bladder, w r hen it is empty, is 



140 PERCUSSION. 

separated from the abdominal anterior wall by 
the inferior circumvolutions of the digestive 
tube, and percussion of the hypogastrium only 
gives out the clear sound of the intestines. 

It is not so when the bladder is distended 
by urine; its base, mounting into the abdo- 
men, passes the pubis ; its anterior face lies 
close to the abdominal wall at a variable 
height, and its presence is recognized by a 
dull sound, circumscribed above by a line 
bent with the convexity upwards. This phe- 
nomenon, which is very easy to prove, becomes 
a valuable symptom of retention of urine, and 
the extent of the dulness, whose superior limit 
rises at times even to the navel, gives us the 
measure of the quantity of liquid accumu- 
lated in the bladder. This dulness is of use 
in distinguishing retention of urine from sup- 
pression, and micturition by redundancy from 
incontinence. It is equally useful in estab- 
lishing the diagnosis between tumefaction of 
the belly, owing to the accumulation of urine 
in the bladder and the development of the 
hypogastrium in cases of uterine pneumatosis. 
At times the distinction will be difficult be- 
tween retention of urine and several ana- 
tomical conditions that also produce a dull 
sound, such as cysts or other solid tumors of 



PATHOLOGICAL PHENOMENA. 141 

the hypogastrium, and especially pregnancy 
and dropsy of the womb. However, in the 
first case, percussion will give on the superior 
limit of the dulness a hydropneumatic sound, 
which will not exist in hydrometra or in preg- 
nancy, and which, for a stronger reason, will 
be wanting when the development of the 
uterus depends on other pathological condi- 
tions, for example, on solid tumors. Besides, 
in all these circumstances, resistance to the 
finger will be greater than in the case of 
urinous tumor; and if some cysts with very 
thin walls do not offer this resistance, if we 
can find a hydropneumatic sound on their 
edges, we must remember that they rarely 
occupy a median position, and that they 
almost never have the fixity of place and the 
symmetrical form of the distended bladder. 

As for ascites, which equally produces dul- 
ness in the hypogastric region, we cannot be 
mistaken in it, by the place which the dull 
sound occupies, circumscribed by a bent line, 
with superior concavity, and especially by this 
decisive characteristic, that it is displaced by 
changes in position of the trunk. 

Uterus. — Hidden in the bottom of the hypo- 
gastrium, in the normal state and when it is 
empty, the womb is inaccessible by palpation 



142 PERCUSSION. 

and is completely hidden from percussion. 
But if it develops itself normally by the pres- 
ence of an embryo, or pathologically by dif- 
ferent morbid conditions, pleximetry will offer 
data, valuable in diagnosis. 

In pregnancy, percussion exercised with care 
will give from the end of the second month 
(according to Mr. Piorry)a dull sound, which 
indicates the development of the uterus. This 
phenomenon, perceived before we can recog- 
nize the increase of the organ by palpation 
at the hypogastrium, by ballottement, and by 
touch, and before we can perceive by auscul- 
tation, the characteristic sounds of pregnancy, 
will be at this epoch an important symptom, 
which will add much to the probability of 
gestation. 

But this result, at a period so little ad- 
vanced, can be obtained only in exceptional 
cases. Later, as the uterus, increasing in 
size, passes the pubis and rises into the ab- 
domen, we easily verify at the hypogastrium, 
by means of percussion, a dulness circum- 
scribed by a bent line with the convexity 
superior, and whose extent, form, and situa- 
tion are in relation to the volume, configura- 
tion, and symmetrical or inclined position of 
the matrix. The characteristics of this dul- 



PATHOLOGICAL PHENOMENA. 143 

ness establish a strong presumption in favor 
of the existence of pregnancy, but they must 
not be regarded as certain proof, and they 
will be insufficient to demonstrate whether 
the development of the uterus is physiologi- 
cal or pathological ; whether it is owing to 
gestation or to dropsy of the uterine cavity, 
or to some other morbid production, such as 
mole, fibrous body, &c. 

The presumption of pregnancy would be 
greater if the progress of the dulness took 
place with the regularity and measure proper 
to the state of gestation ; but we are not 
always in a condition to verify this ascending 
progress, and the semeiotic data of plexim- 
etry are inferior to those that auscultation 
furnishes at this period. However, accord- 
ing to Mr. Piorry, percussion may facilitate 
diagnosis, and cause pregnancy to be recog- 
nized by several other characteristics of the 
dulness, such as its greater intensity and more 
marked resistance to the finger at certain 
points which correspond to the foetus, and its 
less intensity with obscure sensation of fluc- 
tuation at intermediate points ; finally, by its 
displacements, owing to changes in position 
of the foetus, characteristics which will be 



144 PERCUSSION. 

wanting in the before-mentioned pathologi- 
cal conditions. 

By giving similar results, pleximetry will be 
especially useful in establishing the existence 
of pregnancy in cases where auscultation does 
not bring to the ear either the sound of the 
foetal heart or the placental souffle; and it 
may, up to a certain point, aid in determin- 
ing the positions of the foetus. 

In a state of disease, it is almost always by 
a dull sound also that there are revealed the 
lesions of which the uterus may be the seat. 
Thus, in cases of dropsy, of considerable in- 
ternal hemorrhage, or of fibrous bodies of 
great volume, percussion displays a dulness 
whose extent gives the measure of the de- 
velopment of the womb or the dimensions of 
the tumor. Some especial characteristics 
may, besides, serve to give precision to the 
diagnosis; thus, in dropsy or in internal hemor- 
rhage, the dull sound is everywhere equal and 
without remarkable resistance to the finger, 
and the space that it occupies is regularly 
ovoid like the uterus itself, whilst in the case of 
fibrous bodies there is not an intensity every- 
where uniform ; some of the points of the 
organ offer to the finger a resistance more or 
less great, and, besides, the form of the space 



PATHOLOGICAL PHENOMENA. 145 

occupied by the dulness is very irregularly 
rounded. 

It is only in infinitely rare circumstances 
that the uterus can send forth a tympanic 
sound; a considerable accumulation of gas in 
its cavity is alone capable of producing this 
phenomenon. However, this case has some- 
times been observed, and uterine tympanites 
would probably exist, if we found at the hypo- 
gastrium an ovoid tumefaction giving a clear 
sound, circumscribed in every direction, and 
invariable in position. 

As for the appendages of the uterus, their 
most common lesions, capable of affecting 
the sonorousness of the abdomen, are cysts 
of the ovary and of the Fallopian tubes, produ- 
cing a dull sound, that is usually found on 
one side or the other of the hypogastrium, 
and which very rarely assumes a symmetrical 
position in the median region. The dulness 
will be as much more decided, and accom- 
panied by a resistance as much greater as the 
walls of these abscesses are thicker, and as the 
parts contained have more consistence. The 
extent of this dulness will give, in concur- 
rence with palpation, the approximate meas- 
ure of the volume of the tumors. As long 
as they are only of middling dimensions, 

13 



146 PERCUSSION. 

the cysts of the ovary and of the tube will 
not be confounded with ascites; but the case 
is different when they fill the whole abdominal 
cavity. Farther on we shall give the differ- 
ent characteristics of the dull sound in both 
of these diseases (p. 148). 

Peritoneum and abdomen in general. — After 
having studied especially the changes of sono- 
rousness belonging to the principal viscera 
of the abdomen, there remain to be specified 
those which may occupy the whole extent of 
this cavity, and those which, although local- 
ized, may be found indifferently in various 
regions of the abdomen. 

We have seen before (pp. 136 and 137) that 
in peritoneal pneumatosis, we obtain, by per- 
cussion, a clear sound, a tympanic resonance, 
which extends, more or less uniformly, over 
the whole anterior abdominal surface. 

At other times, and much more frequently, 
the abdomen gives out, in its whole extent, 
a more obscure sound; this is observed in 
cases of serous infiltration of the abdominal 
walls, and in those of obesity with thickening 
of the subcutaneous adipose bed, and fatty 
infiltration of the folds of the peritoneum and 
of the deep cellular tissue. 

At times also the whole part which corres- 



PATHOLOGICAL PHENOMENA. 147 

ponds to the intestines gives an obscure sound 
in chronic peritonitis, when false membranes 
exist, thick and infiltrated with tubercles, 
with or without tuberculous degeneracy of 
the mesenteric ganglions, and in these cases, 
palpation is useful in completing the indica- 
tions of pleximetry. 

At other times, percussion points out a 
dulness limited to some point or other of the 
abdomen. It may be owing to a tumor de- 
veloped in one of the organs of which we 
have already spoken ; or depend on a puri- 
form collection, circumscribed in the serous 
cavity, on peri-uterine hsematocele, on a hyda- 
tic cyst, on cancer of the epiploon, or on 
extra-peritoneal abscess of the cellular tissue, 
as is frequently observed in the iliac fossae 
and in the small basin. 

The degree and the extent of the dulness 
will usually give the measure of the density 
and of the volume of these solid or liquid 
tumors, and its seat will sometimes enable us 
to infer the seat and the nature of the lesion ; 
but, in general, the results of percussion will 
not be sufficient for the diagnosis, and in 
order to arrive at an exact knowledge of the 
changes, we must add to the pleximetric in- 
dications, the data furnished by palpation of 



148 PERCUSSION. 

the abdomen, and by the vaginal or rectal 
touch, and must keep an account equally of 
the presence, and of the progress of the con- 
comitant symptoms. 

Diagnosis will be possible by the aid of 
percussion alone, when the dulness, instead 
of being limited to a circumscribed region, 
occupies the whole declining portion of the 
abdomen, and especially when at the same 
time it is liable to be displaced by changes in 
the position of the patient: these characteris- 
tics are sufficient to make us recognize ascites. 

The existence of a liquid effusion in the 
peritoneum would be still more positive, if 
we obtained, by percussing, a hydropneu- 
matic sound on the limits of the dulness, or 
if there was perceived an evident fluctuation. 

There are cases where the dulness occupies 
the whole, or almost the whole of the abdo- 
men, which presents at the same time a very 
great volume. We may then diagnosticate 
almost with certainty the existence of ascites 
or of considerable ovarian dropsy. The dis- 
tinction will be established by the following 
characteristics: in encysted dropsy, the dul- 
ness occupies the most prominent region of 
the distended belly, whilst the clear sound is 
found again at the sides, where the intestines 



PATHOLOGICAL PHENOMENA. 149 

are pushed back by the tumor. In ascites, on 
the contrary, the dull sound occupies all the 
declining part, whilst in the region above the 
navel the presence of the intestines, pressed 
back towards the epigastrium and floating on 
the surface of the liquid, produces a tympanic 
sound, which contrasts with the dulness of 
the rest of the abdomen, whence it is sepa- 
rated by a curved line, with the concavity 
superior. Besides, the fluctuation is much 
more decided in ascites than in encysted 
dropsy of the ovary. 

Besides the different modifications of sono- 
rousness hitherto described, there is one 
that is most frequently discovered in the ab- 
domen, but which may be met with in very 
different regions of the trunk and of the 
members. 

It is a peculiar sound, or rather a mixed 
phenomenon, obtained by percussion, and re- 
sulting from the association of a kind of 
hydropneumatic (humorique) sound with a 
vibratory shuddering, perceived by the hand, 
and designated by the name of watery sound 
or shuddering (bruit oil frernissement hydatique). 
This phenomenon, of which an exact idea can 
be obtained by shaking in the palm of the 
hand an acephalocyst, is actually connected 

13* 



150 PERCUSSION. 

with the existence of hydatids, and depends 
on the oscillation of these vesicles in the sac 
which contains them. This shuddering does 
not take place in all hydatid tumors, there- 
fore its absence will not prove that a spheroid 
tumor of the region of the liver is not an 
acephalocystic cyst; but its presence consti- 
tutes a pathognomonic symptom of this kind 
of disease. 



Sec. HE. — Percussion of the Head, the 
Neck, the Spine, and the Members. 

Among the facts of pleximetry can we place 
the pretended sound of a broken vessel, that 
the cranium is said to yield on percussion, 
in cases of fracture; the particular sound that 
is given by a carious tooth when struck by a 
stylet; the dulness with fluctuation that is 
found on articulations which are the seat of 
hydrarthrus ; &c. ? 

Percussion may have applications more 
real and more useful in cases of fistulous 
abscess, containing gases or air; at times also 
it will be of use in the differential diagnosis 
of anasarca, and of emphysema of the cellular 
tissue, in displaying in the first disease a note- 



PERCUSSION OF THE HEAD, ETC. 151 

worthy dullness, and in the second a sonorous- 
ness accompanied by a dry crepitation under 
the pressure of the finger. 

Mr. Piorry has also proposed to percuss 
upon the vertebral column, or upon the spinal 
regions in order to discover either aneurisms 
of the descending aorta, or deviations and 
changes in volume of the vertebrae, or ab- 
scesses developed in their neighborhood, con- 
secutively to caries. In all these cases it is a 
dull sound that is proved on percussion, and 
the extent and form of this dulness indicate 
the volume and form of these changes. 

Finally, Mr. Stokes, of Dublin, has ad- 
vanced the idea that percussion cannot be 
without utility in diagnosis of diseases of the 
larynx.* But, before him, Mr. Piorry had 
already pointed out all the opinions relative 
to this subject :f " Percussion of the larynx 
or of the trachea can hardly be made, except 
mediately. In order to practise it, we must 
fix the trachea and the larynx, by the aid of 
the pleximeter, quite strongly applied to these 
conduits. In the normal state, the finger 
finds elasticity, and the ear hears sonorous- 

* A Treatise on the Diagnosis and Treatment of Diseases of 
the Chest, 1837. 

t Treatise on Diagnosis, v. i, p. 412. (Traite de Diagnostic.) 



152 PERCUSSION. 

ness upon the points which correspond to these 
organs. There are very few pathological 
cases where it will be otherwise; only, if it 
should happen that a tumor having its seat 
on the neck surrounded the trachea and the 
larynx, we might make use of percussion in 
order to determine the place that they should 
occupy. The presence of liquids in the ven- 
tricles of the larynx might sometimes produce 
the hydropneumatic sound. The accidental 
opening of the larynx, followed by the pene- 
tration of air into the neighboring cellular 
tissue, might be suspected if percussion dis- 
covered at the neck an unaccustomed sono- 
rousness in connection with emphysema. In 
case of a soft and depressible tumor, situated 
upon the larynx, we might judge of the depth 
at which this is situated, by that at which we 
should obtain sonorousness in pressing upon 
the tumor with the pleximeter and in per- 
cussing afterwards." 



Percussion and Auscultation Combined. 

Laennec had the idea of combining auscul- 
tation and percussion; he had proposed the 
simultaneous employment of these two modes 



PERCUSSION AND AUSCULTATION. 153 

of examination in certain cases of ascites and 
of pneumothorax;* to these we usually have 
recourse in order to make known and better 
to perceive the hyclatic sound (bruit hydatique). 
Two physicians of the United States, Messrs. 
Cammann and Clark, have gone farther: 
they have generalized this mixed method ;f 
they have traced its rules, and exposed its ad- 
vantages in physical diagnosis. We propose 
to give a summary analysis of their work :J 
" When a sound is obtained by ordinary per- 
cussion on the human body, a thousand parts 
are dispersed and lost for one which comes 
to the ear; but if we could receive the sono- 
rous vibrations at the end of a solid, elastic, 



* " We may," says he, " estimate the extent of space occu- 
pied by the air in auscultating and percussing at the same time 
at different points ; there is then heard a resonance like that of 
an empty cask, and mingled at times with tinkling" (tinte- 
rtient). (Vol. i, p. J39.) Mr. Piorry likewise indicated in 1826 
(Treatise on Mediate Percussion, p. 18, and Operation of Per- 
cussion, p 26), the combined use of percussion and of ausculta- 
tion ; Mr. Donne pointed it out under the name of acmtophonie ; 
and Mr. Fournet, who reports the fact in his Clinic Researches 
(p. 561), says that he tried this mode of investigation without 
having been able to make any useful application of it. 

f A New Mode of Ascertaining the Dimensions, Form, and 
Condition of Internal Organs, by Percussion and Auscultation. 
(New York Journ.of Med. and Surg., July, 1840.) 

% See the detailed analysis and the experiments made by one 
of us. (Medical Union, 1850.) (Union Medicate,) 



154 PERCUSSION. 

homogeneous body, very little would be lost 
by irradiation, and almost all would be per- 
ceived at the other end. Although the vi- 
brations be thus conducted through a small 
surface, the sound gains much in clearness 
and in intensity. 5 ' 

Setting out from this principle, the Ameri- 
can physicians propose, for auscultation, to 
use, in place of the ordinary stethoscope, a 
solid cylinder of cedar wood, cut in the di- 
rection of the ligneous fibres, five or six inches 
long, and about ten lines in diameter, fur- 
nished with a plate on which the ear rests.* 
For percussion, the pleximeter is employed. 
The operator may proceed thus in ausculta- 
tory percussion: let the cylinder be placed 
over the central part of the organ to be ex- 
plored, and let one observer auscultate while 
another percusses, with very light blows, with 
a single finger. Messrs. Cammann and Clark 
also observe that with a little exercise it is 
possible for the same individual to percuss and 

* The cylinder ought to pass a little beyond the level of the 
plate, in order to be applied directly to the tube of the ear j 
without change of medium (a solid cylinder with a smooth plate, 
all of the same piece, has appeared preferable to us). We may 
make use, for auscultation of the chest, of an instrument cut at 
an angle at its lower part, which depresses better the intercostal 
spaces without touching the ribs. 



PERCUSSION AND AUSCULTATION. 155 

auscultate at once. Whatever method be 
employed, we strike at first some blows upon 
the pleximeter, quite near to the stethoscope, 
in order to have the representative sound 
(son type) of the viscera ; we then remove by 
degrees until other mediums give sounds 
entirely different. If we wish to verify this 
first result, there is an advantage in setting 
out, on the contrary, from a point of the cir- 
cumference and approaching the centre : be- 
sides, care must be taken to mark in succes- 
sion the points where the sound appears more 
or less to vary. 

The American physicians have established 
typical sounds (sons types), to which others 
may be compared; at the extremes of the 
scale they have placed the sound given by a 
bone and that supplied by a liquid contained 
in the thorax or abdomen. 

" The osseous sound is most easily dis- 
tinguished from the others; its tone is very 
elevated, very intense ; it strikes the ear with 
a painful force; it is full and loud, and is 
propagated to a great distance ; it is a little 
prolonged and slightly metallic. 

" The aqueous sound is very imperfectly 
transmitted through the abdominal or tho- 
racic walls, it is rather recognized by its nega- 



156 PERCUSSION. 

tive properties; in the abdomen it is rapid, 
as if under the ear, acute, of a medium in- 
tensity, non-elastic, much less conductible, 
and less impulsive than the osseous sound." 

In the thorax, this aqueous sound has char- 
acteristics still less distinct; it entirely re- 
sembles that of the healthy lung : hence the 
facility of distinguishing a solid or indurated 
organ from a liquid contained in the chest. 

" The cardiac sound approaches the osseous 
sound; it has its acuteness, clearness, and 
conductibility, but to a less degree ; it is 
rapid, immediate, intense, impulsive, and a 
little painful to the ear; it has, principally at 
the circumference of the heart, as it were a 
muffled metallic tone. 

" The hepatic sound, compared to the car- 
diac, is graver, more continuous, less freely 
conducted by the organ where it is formed ; 
but it is clear, intense, immediate, and im- 
pulsive. 

" The normal pulmonary sound, and that of 
pneumothorax or of abdominal pneumatosis, 
differ from the preceding ; but for these cases, 
ordinary percussion is preferable, the sonor- 
ous vibrations being then better conducted by 
the air than by a solid medium." 

With the new method, it should be possible 



PERCUSSION AND AUSCULTATION. 157 

to bound and to measure solid organs, " in all 
conditions of health or of disease, with almost 
as much exactness as if they were under the 
eye," either the heart (and all its diameters, 
except the antero-posterior), or the liver, or 
yet the spleen or even the kidneys. 

It is especially to the measurement of the 
heart, that Messrs. Oammann and Clark ap- 
plied themselves; they recommend it to be 
drawn by means of four diameters, which they 
trace upon the precordial region,* and of 
eight points at a nearly equal distance, which 
they mark upon the circumference of the 
organ ; and these traced diameters are meas- 
ured by turns, are compared to the normal 
mean, either isolated or reunited, and from 
the sum of the lengths can be specified the 
dimensions of the heart, and the augmenta- 
tion of its volume rigorously calculated. 

* 1st. Vertical diameter ; begins at the base of the heart, 
just outside of the orifice of the aorta, and extends downwards 
in a parallel line with the median line of the body. 2d. Trans- 
verse diameter ; cuts the first line at a right angle near its cen- 
tre. 3d. Oblique right diameter ; from the superior right edge 
of the right auricle to the point of the heart, following a line 
drawn from the top of the right shoulder. 4th. Oblique left 
diameter ; cuts the line of the oblique right diameter at a right 
angle, and finishes at the point where the left auricle and the 
left ventricle unite. 

14 



158 PERCUSSION. 

The normal mean of these four united dia- 
meters being found upon the dead body, to 
be 17 inches in man, and 16 inches, 1 line in 
woman, the result is, according to the authors 
of auscultatory percussion, that if the sum 
of the diameters calculated by their method, 
exceeds these means, if especially it rises 
above 17 inches, we must conclude that the 
heart is augmented in volume. If it equals 
18 inches, 8 lines, the existence of an organic 
affection with dilatation is almost certain; 
whilst if the total of the diameters is inferior 
to the fore-mentioned means, it is not proba- 
ble that there is enlargement in the dimen- 
sions of the heart. 

The application of percussion and of aus- 
cultation combined, has also been made to 
the diagnosis of some surgical lesions of the 
osseous system, principally of fractures. 

When a bone is broken, if we auscultate 
upon one of the broken parts, percussion 
being practised upon the other, the osseous 
sound whose characteristics have already been 
specified, is transmitted to the ear modified in 
its nature ; it is less pure and less perfect. If 
the broken parts are still touching each other, 
even by a single point, the sound will be less 
intense and less impulsive, the modification 



PERCUSSION AND AUSCULTATION. 159 

being, however, very slight; but let the least 
separation exist, the sound and the shock will 
be immediately lost. 

The mixed method of percussion and of 
auscultation may bring about new progress 
in physical diagnosis, and it is to be desired 
that observers should study it seriously, in 
order to give a rational decision as to its defi- 
nite value. From the experiments that we 
have made, we are disposed to admit that it 
may, in effect, be of use in limiting solid 
organs. It is in measuring the heart that 
it has seemed to us that it must be most use- 
ful. As the smallest permanent changes in 
the volume of this viscera are of great seme- 
iotic value, it follows that a rigorous estima- 
tion of its dimensions, and an exact drawing 
of its different cavities, is a problem as im- 
portant as it is difficult to solve, and we be- 
lieve that by the new operation, a singularly 
exact measurement of the heart may be ob- 
tained. After a certain number of experi- 
ments, we were able without great effort to 
discover the limits of the organ with an ex- 
actness at times surprising, and to distinguish 
the point of origin pf the great vessels or the 



160 PERCUSSION. 

line of separation of the ventricles and auri- 
cles. 

But whatever may be said by Messrs. Cam- 
mann and Clark, and in spite of the authority 
of the physicians of America,* the manual of 
operation has appeared to us to present some 
difficulty. If, indeed, we make use of an 
assistant in percussing (according to the 
method indicated in the memoir of the in- 
ventors), how many inconveniences there are, 
in clinic and especially in civil practice, in a 
method of examination which demands the 
simultaneous co-operation of two observers. 
Then if one person endeavors to auscultate 
himself and to percuss at the same time (as the 
American physicians now do, and as we have 
endeavored to do ourselves), he is certainly 
incommoded in this double operation. Is it 
easy to percuss, when it is necessary to fix 
the stethoscope with the head upon the chest 
or the abdomen of the patient ? Is it easy in 
this posture to carry the pleximeter around 
the cylinder in every direction, and to move 



* We are informed by our honorable associate and friend, 
Dr. Keene, that the new method is preferred in the New York 
hospitals, principally for measuring the heart, and that it is 
always practised by a single observer. 



PERCUSSION AND AUSCULTATION. 161 

it sometimes only a few lines, sometimes to a 
considerable distance ? Finally, this rather 
laborious and necessarily prolonged explora- 
tion does it not exact from the patient a good- 
will and a co-operation which are wanting in 
many cases ? 

To sum up : auscultatory percussion ap- 
pears to us difficult of execution; its pro- 
found study must demand at least as much 
time as ordinary percussion ; if it can rival 
the latter in measuring solid or indurated 
organs, even if it allows us perhaps to appre- 
ciate more exactly the precise dimensions of 
the heart, it is certainly inferior in the ma- 
jority of cases, and especially in examining 
the rarer mediums. 

Besides, ordinary percussion and isolated 
auscultation, if the finger and the ear be 
sufficiently exercised, appear to suffice for all 
the exigencies of diagnosis. 




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